Form 5304 - Missouri Tobacco Directory - Non-Participating Manufacturer Certification Page 2
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3PART 7: BRAND FAMILY AND BRAND STYLE IDENTIFICATION
A. Brand Family and Brand Style: For each brand style which the company requests for certification or for which the company received certification in a prior year,
the following information is to be provided on the Form 5303 Missouri Tobacco Directory - Non-Participating Manufacturer Brands Certification:
•
Name: List the brand family and style as follows - brand family/brand style/flavor/size/container. Those brand styles that will not be sold in the current year
*).
should be marked with an asterisk(
•
Cigarette or Roll-Your-Own (RYO): Indicate whether the product is a cigarette or RYO.
•
Packaging Submitted: Indicate if packaging sample is being submitted.
•
Current Manufacturer: Include the name and address of the current manufacturer.
•
Prior Manufacturer(s): Include the name and address of all prior manufacturers.
•
Units Sold - Prior Year: Indicate the number of units sold during the prior calendar year.
•
Units Sold - Current Year To Date: Indicate the number of units sold during the current calendar year.
•
Current Trademark Holder: Include the name and address of the current trademark holder.
•
Prior Trademark Holder: Include the name and address of all prior trademark holders.
B. Additional Information: Check the appropriate box(es):
Initial or Supplemental Certification: Included with this certification is corresponding actual cigarette or RYO packaging (without tobacco) for each brand
style for which company requests certification.
Annual Certification - No Packaging Changes: Corresponding actual cigarette or RYO packaging (without tobacco) has been previously provided and
there have been no changes to the packaging.
Annual Certification - Packaging Changes/Brand Additions: There have been changes to the packaging samples previously submitted or new brand
styles have been added. Corresponding actual cigarette or RYO packaging (without tobacco) is included.
FSC (Fire Safe Compliance): Attached is a letter from the Missouri State Fire Marshal’s Office indicating that the brand styles for which company seeks
certification are FSC compliant.
Brand Responsibility: The company identified in Section 2 affirms that the cigarettes or RYO brands listed herein are to be considered the company’s
cigarette and RYO brands for the purpose of calculating the company’s payments for the purposes of section 196.1000 to 196.1003, RSMo.
PART 8: ADDITIONAL BUSINESS INFORMATION
CHECK ONE
DOES NOT
RESPONSE
ATTACH THE FOLLOWING DOCUMENTS OR INFORMATION:
PROVIDED
APPLY
Initial Certification
Partnership or Association: Current copy of the Certificate of Partnership or the certificate required to be filed by any state,
county or municipality.
Corporation: 1) Current copy of the Certificate of Incorporation or other charter and 2) extracts of documents listing the
officers authorized to sign for the company.
LLC or other entity: Current copy of the business documents filed with a state, county, or municipal entity when such filing is
required. Include a copy of any document indicating persons authorized to sign for the entity.
Organizational Documents - Annual/Supplemental Certification
No Changes to Organizational Documents: Organizational documents were submitted with the initial Certification
Application. There have been no changes to the organizational documents previously submitted.
Organizational Documents Have Changed: There have been changes to the organizational documents previously
submitted. Copies of all updated documents are attached.
Company Officers/Owners: Provide a list of all company officers and company owners (all persons with an equity interest of
10% or more in the company). Include name, address, phone number and e-mail address.
Affiliates: Provide a list of all company Affiliates that also manufacture, import, distribute, or sell cigarettes or RYO. Include
the name, address and contact information for each Affiliate.
Marketing Information: For each brand family, list the name, address and contact information for each Missouri wholesaler
through which the company intends to sell cigarettes or RYO in Missouri.
Agreements with Participating Manufacturers: Identify every agreement between the company and any Participating Manu-
facturer (“PM”) or PM Affiliate that relates to the making, importing, distribution, transportation, or sale of each Brand Family.
Agreements Regarding Compliance with the Qualified Escrow Statute: List every Brand Family that is the subject of any
agreement regarding compliance with a Qualified Escrow Statute.
Health Warning Rotation Plan: For each Brand Family, list the name and address of the entity that filed cigarette health
warning rotation plan with the Federal Trade Commission. Attach the Federal Trade Commission’s written approval of the
company’s annual Cigarette Health Warning Rotation Plan. Applies only to cigarettes.
Ingredient Report: For each Brand Family, list the name and address of the entity that submitted the ingredient reporting
information to the U.S. Secretary of Health and Human Services as required by the Federal Cigarette Labeling and Advertising
Act. Attach copies of all Certificates of Compliance received from the U.S. Secretary of Health and Human Services for the
company’s annual ingredient reporting required by the Federal Cigarette Labeling and Advertising Act (15 USC § 1335a).
Applies only to cigarettes.
Imported Cigarettes: If company sells or intends to sell cigarettes or RYO brands that are not manufactured in the United
States, provide the following:
A copy of the sworn statement of the original manufacturer that it will timely submit ingredient information to the
Secretary of Health and Human Services as required by 19 USC §1681a(c)(1). Cigarettes Only.
A copy of the importer’s certificate under penalty of perjury as required by 19 USC §1681a(c)(2) regarding the
precise format of warnings and the rotation plan for health warning. Cigarettes Only.
A copy of the trademark holder’s certificate under penalty of perjury that it has not withdrawn consent to import
into the United States as required by 19 USC §1681a(c)(3)(A) or a copy of the importer’s certificate under penalty
of perjury that the trademark owner has not withdrawn consent to import into the United States as required by
USC §1681a(c)(3)(B).
Internet or Mail Order Sales: If company intends to sell any Cigarettes (including RYO tobacco) by mail order or via the Internet.
Security Interest: Please identify any person or entity, other than a regulated financial institution, with a security interest or
security interests in assets of the company that exceed 10% of the value of all of the company’s gross assets (i.e., not counting
assets after deducting liabilities). Attach all security agreements and financing statements for the security interests, and provide a
listing of where the financing statements have been filed to perfect the security interests.
DOR-5304 (10-2011)
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