Form 1783 - South Dakota Tobacco Product Manufacturer Complementary Legislation Certification Page 5

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PART 3: NON-PARTICIPATING MANUFACTURER MARKETING AND DISTRIBUTION INFORMATION
Complete for all distributors, wholesalers, and retailers* selling manufacturer’s product(s) into South Dakota to
which the Non-participating Manufacturer identified in Part 1 has sold cigarettes and/or RYO tobacco. Attach
additional sheets if necessary.
*UNDER SOUTH DAKOTA LAW, ONLY LICENSED DISTRIBUTORS OR LICENSED WHOLESALERS MAY SELL
CIGARETTES OR RYO TOBACCO TO RETAILERS.
Name
Address and Phone
Identify whether a
Brand
Number
Distributor, Wholesaler, or
Retailer
PART 4: NON-PARTICIPATING MANUFACTURER TRADEMARK INFORMATION
Provide documentation of the trademark holder of each brand family. If trademark holder is different than
applicant, then provide an explanation of the relationship between the two entities. Attach additional sheets if
necessary.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PART 5: NON-PARTICIPATING MANUFACTURER ORGANIZATION INFORMATION
If applicant is a:
Attach to certification
Partnership or association
Current copy of articles, if any, OR the certificate
required to be filed by any state, county, municipality,
or tribal entity.
Corporation
1. Current copy of corporate charter OR certificate of
corporate existence or incorporation.
2. Extracts of stockholders’ meetings, bylaws,
directors’ meetings or other documents that show that
person signing this certification has authority to act on
behalf of the corporation.
Limited liability company or other business
Current copy of the business documents filed with the
organization
state, county, municipality, or tribal entity when such
filing is required. A limited liability company must
provide an accurate copy of its operating agreement.
5

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