Form 114780 - Npm Information Request printable pdf download

Form 114780 - Npm Information Request

State of Tennessee

NPM Information Request

Pursuant to Tenn. Code Ann. §§ 67-4-2601 et seq.

Please type or legibly print in permanent blue ink. Use additional pages as necessary. (This Form may be filled out on-line,

however, all signatures must be executed in permanent

blue

ink.)

Applicant name:

Street Address:

City/State/Zip/Country:

Mailing Address (if different from above):

City/State/Zip/Country:

Telephone number:

Facsimile number:

E-mail address:

The following documents must be attached to your 2013 Certification Form for Listing on Tennessee’s Directory. Initial

by each number to confirm that each document requested is attached and labeled appropriately:

Samples - Samples (or legible, identical size, color copies of all sides of the packaging thereof) of the

current packaging and labeling used for each of the individual brands within each Brand Family listed in

Part 3 of the 2013 Certification Form for Listing on Tennessee’s Directory. Initial to confirm that you

have attached these documents.

Permits & Licenses to Manufacture Cigarettes - A copy of all permits, licenses or other authorization to

manufacture tobacco products issued by any governmental entity, whether located in the United States or

elsewhere. This includes importer’s certificate, trademark holder’s certificate, etc. Initial to confirm that

you have attached the requested documents.

Certificate of Compliance (cigarettes only) - A copy of the current Centers for Disease Control (CDC)

ingredient-listing compliance letter(s) pertaining to the brands listed in this certification and a statement

from the manufacturer as to which brands’ ingredients were submitted for each approval letter. Initial to

confirm that you have attached the requested documents.

Page 1 of 5

Official TN Form 114780

December 26, 2012

Form 114780 - Npm Information Request