State Of New Jersey Non Participating Manufacturer

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State of New Jersey
NPM-AI
Non-Participating Manufacturer
Certification of Additional Information
Part 1: Certification Year and Type of Certification
Certification Year: Complete a separate form for each Certification year that you are
2009
certifying. Certification year 2009 is for sales made in 2008. (check one)
Other: ______
Type of Certification:
Initial
Annual
Supplemental
(check one)
Part 2: M anufacturer Identification
Company Name
Name and Title of Person Completing this Form
Mailing Address
City
State
Zip Code
Country
Phone
Fax
FEIN
Part 3: NPM Status
References to cigarettes (includes roll-your-own tobacco) are to the brand families certified on the NPM-AI form submitted by the
manufacturer identified in Part 2.
NPM is the fabricator of the brand families listed on the NPM-AI form and intends for the cigarettes to be sold in
Yes
No
the U.S., including cigarettes intended to be sold in the U.S. through an importer.
NPM is the first purchaser anywhere for resale in the U.S. of cigarettes manufactured anywhere that the
Yes
No
manufacturer does not intend to be sold in the U.S.
Part 4: Additional Information Requested by Attorney General’s Office
All NPMs must provide the information requested in this section. Provide a response to each question. All attachments must indicate the
A.
question to which it corresponds.
A listing of all company officers and owners (all persons with an equity interest of 10% or more in company).
1.
2.
A complete list of cigarettes (including roll-your-own tobacco “RYO”) that NPM, its principals, subsidiaries, affiliates,
successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those
brands; and place of manufacture for those brands.
List the cigarettes and RYO by brand name, brand family and flavor (other than tobacco, menthol, clove).
3.
A complete list of tobacco products (e.g. cigars, pipe tobacco, smokeless tobacco, etc.) that NPM and its principals,
subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for
manufacture of those brands; and the place of manufacture for those brands.
4.
Provide names, addresses, telephone numbers, and, if available, email addresses of all tax stamping agents (licensed or not) the
NPM sells cigarettes to (including RYO) located in New Jersey or another State.
5.
Provide names, addresses, telephone numbers and, if available, email addresses of all the retailers, importers, distributors,
wholesalers or similar intermediaries the NPM sells cigarettes to (including RYO) located in New Jersey or another State.
6.
Provide a list of States that have certified the NPM and the brand families certified in those States. If any State has refused to
list or removed NPM from a State’s directory, identify the State(s).
7.
List all internet websites where NPM cigarettes or tobacco products are sold, even if without NPMs express authorization.
Provide the name, address and telephone number of owner of the domain name of the website. Provide a separate listing for
each brand of cigarettes or tobacco products if necessary.

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