Form 114780 - Npm Information Request (Page 4 of 5) in pdf

16.

Organizational Documents required to be provided with Certification application

IF APPLICANT IS A:

ATTACH TO CERTIFICATION FOR THE FOLLOWING:

Current copy of articles, if any or the certificate required to be filed by any state, country or

Partnership or Association

municipality along with verification that the document(s) was filed with the appropriate

governmental agency.

Corporation

A copy of the Company’s corporate charter or certificate of corporate existence or

incorporation along with verification that the document(s) was filed with the appropriate

governmental agency. This copy must be executed by the appropriate state officer for the

jurisdiction of incorporation.

AND

Extracts from stockholders’ meetings, bylaws, directors’ meetings or other documents that list

the officers authorized to sign documents or otherwise act on behalf of the corporation. The

accuracy of the extracts provided by the Company must be certified by an appropriate officer

of the corporation.

Limited Liability Company

Current copy of the business document(s) filed with a state, county or municipality if such

filing is required along with verification that the document(s) was filed with the appropriate

governmental agency.

AND

An accurate copy of its operating agreement.

Other business organization

Current copy of the business document(s) filed with a state, county or municipality of such

filing is required along with verification that the document(s) was filed with the appropriate

governmental agency.

_____ 17

Escrow Agreement.

Attach a copy of the company’s current escrow agreement including any

amendments that have been executed thereto. Initial to confirm that a current copy of this agreement is

attached.

____ 18.

NPM Bond. Attach official form number 092809 if you are a “newly qualified” NPM. Please see Tenn.

Code Ann. § 67-4-2602 to determine whether your company meets this definition. A sample form of such

a bond is located online at

along with a copy of

the bond required by Tennessee Code Annotated section 67-4-2602 in the amount of $100,000. Initial to

confirm that the bond information is attached or list “N/A” if not necessary.

_____ 19.

Sales

Attach a list of states in which you are currently listed on the directory of compliant tobacco

product manufacturers or in which you sell your tobacco products. Initial to confirm that this information

is attached.

_____ 20.

Fire Safety. Provide copies of the verification of your company’s compliance with Tennessee’s fire-safe

cigarettes requirements from the Tennessee Department of Commerce and Insurance, Division of Fire

Prevention. Initial to confirm that this information is attached.

Page 4 of 5

Official TN Form 114780

December 26, 2012

Form 114780 - Npm Information Request Page 4

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