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COMPTROLLER OF MARYLAND

P.O. Box 2397

FIELD ENFORCEMENT DIVISION

ANNAPOLIS, MD 21404-2397

MATT REGULATORY BUREAU

410-260-7494

MARYLAND FIRE SAFETY PERFORMANCE STANDARD FOR CIGARETTES

MANUFACTURER'S CERTIFICATION FORM

Part I:

Type of Certification (Check One)

____ Initial ____ Supplemental ___ Three Year Recertification

Part II: Manufacturer Identification

Company Name:

Mailing Address:

Street

City

State

Zip

Business Phone Number:

FEIN:

Business Fax Number:

Country:

Name of Person Completing this form:

Title of Person Completing this form:

Part III: Cigarette Brand Certification (Use COM/FED-302-1 Addendum, as necessary)

Pursuant to Business Regulation, § 16-603 of the Annotated Code of Maryland, please describe each cigarette as follows:

BRAND

STYLE

TEST DATE (S)

LENGTH (mm)

FLAVOR

Menthol

Non-Menthol

Check the

FILTER OR NON-

appropriate

CIRCUMFERENCE (mm)

Filter

Non-Filter

FILTER

box

MARKING

PACKAGE

Hard Pack

Soft Pack

Crush Proof Box

BRAND

STYLE

TEST DATE (S)

LENGTH (mm)

FLAVOR

Menthol

Non-Menthol

Check the

FILTER OR NON-

appropriate

CIRCUMFERENCE (mm)

Filter

Non-Filter

FILTER

box

MARKING

PACKAGE

Hard Pack

Soft Pack

Crush Proof Box

BRAND

STYLE

TEST DATE (S)

LENGTH (mm)

FLAVOR

Menthol

Non-Menthol

Check the

FILTER OR NON-

appropriate

CIRCUMFERENCE (mm)

Filter

Non-Filter

FILTER

box

MARKING

PACKAGE

Hard Pack

Soft Pack

Crush Proof Box

Part IV: Certification Oath and Signature

A. The undersigned manufacturer certifies, under penalty of perjury, as of this date of this certification, it is a cigarette manufacturer as defined

under Business Regulation Article ("BR"), § 16-601(d) of the Annotated Code of Maryland ("Code"), and is in full compliance with the Fire Safety

Cigarette Performance Standard of Cigarettes, and any rules and regulations promulgated thereof by the Comptroller of Maryland. It is further

certified that each cigarette brand has been tested in accordance with ASTM standard E2187-04 "Standard Test Method for Measuring the Ignition

Strength of Cigarettes," and has met the performance standard set forth in BR, § 16-602 of the Code.

B. The undersigned manufacturer further certifies, under penalty of perjury, that it will timely provide a copy of each certification to each

wholesaler to whom it sells cigarettes, including copies of an illustration of the package marking approved by the Comptroller of Maryland in

accordance with BR, § 16-605 of the Code.

Witness the due execution hereof on this _____ day of _____________, 20____, I set forth my hand and seal to be legally bound as the

manufacturer making this certification under the laws of the State of Maryland:

By:

Title:

COM/FED-302 Rev. 4/11

Form Com/fed-302 - Maryland Fire Safety Performance Standard For Cigarettes Manufacturer'S Certification Form

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