Form Tt-19-Npm - Tobacco Product Manufacturer Certification For Non-Participating Manufacturers Page 2

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Company Phone:
Contact:
Title:
Phone:
Fax:
Email:
Website:
Name, Title and Dates of Service for all Current and Past Officers, Directors and/or Partners:
If the Tobacco Product Manufacturer is represented by outside counsel for the purpose of
compliance with Va. Code § 3.1-336.1 et seq., provide the following information:
Firm:
Attorney:
Address:
Email:
Phone:
Fax:
Part 3: Registered Agent for Service of Process within the Commonwealth of Virginia Agent:
Company:
Address:
Phone:
Fax:
Email:
• A current statement from the registered agent certifying service in this capacity must be
attached to the Certification.
Page 2 of 9

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