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State of Connecticut

Form TPM-2

Certiﬁ cation for Listing in the Connecticut Tobacco Directory

as of July 1, 2013

(Rev. 04/13)

This application will not be processed or considered complete until all the information and documents required, either by the application

form, the instructions to the application form, or by the request of the Department of Revenue Services (DRS) or the Ofﬁ ce of the Attorney

General, have been submitted.



Initial

Supplemental

Complete this form in blue or black ink only.

Part I: General Business and Ownership Information

For completion by participating manufacturers (PMs) and nonparticipating manufacturers (NPMs)

Applicant tobacco product manufacturer identiﬁ cation



Applicant: _______________________________________________________________________________________________

Street address: ___________________________________________________________________________________________

_______________________________________________________________________________________________________



Mailing address if different from above: ________________________________________________________________________

_______________________________________________________________________________________________________

Telephone number: _________________________________Facsimile (Fax) number: ___________________________________

Email address: ___________________________________________________________________________________________

Website address: _________________________________________________________________________________________

Name and title of authorized ofﬁ cer completing this certiﬁ cation: ____________________________________________________

_______________________________________________________________________________________________________

Manufacturing plant(s) name and street address if different from above: ______________________________________________

_______________________________________________________________________________________________________

Manufacturing plant telephone number: ________________________________________________________________________

Manufacturing plant fax number: _____________________________________________________________________________

Name, title, and telephone number of contact person at plant if different from above: ____________________________________

Attach additional sheet(s) as necessary to provide a complete response.

Attach a photograph or diagram of the manufacturing (fabricating) facility and indicate on the photograph or diagram where the

equipment and facilities for manufacturing the cigarettes, if any, are located.

The undersigned certiﬁ es that as of the date of this certiﬁ cation, the applicant named above is a (initial one):

___

Participating manufacturer (PM) as the term is deﬁ ned in Section II(jj) of the Master Settlement Agreement (MSA) that has

in the past generally performed and is currently generally performing its ﬁ nancial obligations under the MSA.

___

Nonparticipating manufacturer (NPM) that is in full compliance with Conn. Gen. Stat. §4-28i and implementing regulations

including having made all required deposits into a qualiﬁ ed escrow fund for all the years beginning with calendar

year 2000.

The applicant is the manufacturer (fabricator) of all of the brand families listed in this certiﬁ cation which are intended to be

sold in the United States, including cigarettes intended to be sold in the United States through an importer.







 

Yes

Form Tpm-2 - Certification For Listing In The Connecticut Tobacco Directory As Of July 1, 2013

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