Fillable Form 20: State of Oregon Participating Manufacturer Certification (Columbia Gorge Community College)

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Form 20: State of Oregon Participating Manufacturer Certification (Columbia Gorge Community College)

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Participating Manufacturer Certification
DM#6326172-V5 (Revised: 04-06-2020) Page 1 of 4
State of Oregon
Participating Manufacturer Certification
For Listing on the Oregon Tobacco Directory
Part 1: Liability Year and Type of Certification
Liability Year for this Certification:
Complete a separate form for each liability
year for which you are certifying (check one):
20
Other:
Type of Certification (check one): Initial Annual
Supplemental
Part 2: Manufacturer Identification
Applicant Company Name: FEIN No.
Mailing Address:
City:
State:
Zip:
Country:
Phone:
Fax:
Email:
Name of Person Completing Certification:
Part 3: Manufacturing Facility Information
Plant Name:
Physical Address:
City:
Zip:
Country:
Plant Phone:
Plant Fax:
Name/Title of Person at Plant (if different than above):
Part 4: Licenses and Permits
U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number:
Foreign Manufacturer Permit or License Number: Country Issued:
Last Year Permit or License Issued: Is Permit/License Current: Yes No
Initial Certification or Changed Permit: A copy of current permit is attached.
Annual or Supplemental Certification: A copy of Applicant’s current permit was submitted
with a prior certification and there have been no changes to the permit.
Part 5: Brand Family and Brand Style Identification
A. Brand Family and Brand Styles: For each brand style for which Applicant is seeking
certification or for which Applicant received certification in a prior year, the following information is
attached:
Name: List the brand family and style as follows: – brand name/flavor/size/container. Those
brand styles that will not be sold in the current year should be marked with an asterisk (*).
Cigarette or RYO: Indicate whether the product is a cigarette or RYO.
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Participating Manufacturer Certification
DM#6326172-V5 (Revised: 04-06-2020) Page 2 of 4
B. Additional Information: Check the appropriate box(s):
Initial or Supplemental Certification: Included with this Certification is corresponding actual
cigarette or RYO packaging (without tobacco) for each Brand Style for which Applicant requests
certification.
Annual Certification – No Packaging Changes: Corresponding actual cigarette or RYO
packaging (without tobacco) has been previously provided and there have been no changes to
the packaging.
Annual Certification – Packaging Changes/Brand Additions:
There have been changes to
the packaging samples previously submitted or new brand styles have been added.
Corresponding actual cigarette or RYO packaging (without tobacco) is included.
FDA Compliance:
(For initial or supplemental certifications or brand additions). Check the
appropriate box and provide the requested documentation for each brand style that is new to
the Oregon Tobacco Directory.
The product was first commercially marketed on or before February 15, 2007. Please
provide correspondence from the FDA showing that the product has been granted
grandfather status from the premarket review process or evidence that the product was
commercially marketed before February 15, 2007.
The product was first commercially marketed after February 15, 2007 but before March 22,
2011. Please provide either (1) evidence that a substantial equivalence application was
filed with the FDA or (2) a substantial equivalence order.
The product was first commercially marketed on or after March 22, 2011. Please provide
either (1) a substantial equivalence order or (2) an order approving a premarket review
application.
Health Warning Rotation Plan: For each Brand Family, list the name and address of the
entity that filed cigarette health warning rotation plan with the Federal Trade Commission.
Attach the Federal Trade Commission’s written approval of the Applicant’s annual Cigarette
Health Warning Rotation Plan. Applies only to cigarettes.
Ingredient Report: For each Brand Family, list the name and address of the entity that
submitted the ingredient reporting information to the U.S. Secretary of Health and Human
Services as required by the Federal Cigarette Labeling and Advertising Act. Attach copies of all
Certificates of Compliance received from the U.S. Secretary of Health and Human Services for
Applicant’s annual ingredient reporting required by the Federal Cigarette Labeling and
Advertising Act (15 USC §1335a). Applies only to cigarettes.
Imported Cigarettes: If applicant sells or intends to sell cigarettes or RYO brands that are not
manufactured in the United States, provide the following:
A copy of the sworn statement of the original manufacturer that it will timely submit
ingredient information to the Secretary of Health and Human Services as required by 19
USC §1681a(c)(1). Cigarettes Only.
A copy of the importer’s certificate under penalty of perjury as required by 19 USC
§1681a(c)(2) regarding the precise format of warnings and the rotation plan for health
warnings. Cigarettes Only.
A copy of the trademark holder’s certificate under penalty of perjury that it has not
withdrawn consent to import into the United States as required by 19 USC §1681a(c)(3)(A)
or a copy of the importer’s certificate under penalty of perjury that the trademark owner
has not withdrawn consent to the import into the United States as required by
§1681a(c)(3)(B).
FSC (Fire Standard Compliance): Attached are: a) letter from the Oregon Fire Marshal’s
Office indicating that the brand styles for which Applicant seeks certification are FSC compliant;
and b) testing verification documentation for each corresponding brand style.
Participating Manufacturer Certification
DM#6326172-V5 (Revised: 04-06-2020) Page 3 of 4
Part 5B: Additional Information, Continued.
Brand Responsibility: The Applicant identified in Section 2 affirms that the cigarette and RYO
brands listed herein are to be considered the Applicant’s cigarette and RYO brands for the
purposes of calculating the applicant’s payments under the MSA
.
Part 6: Distributors
Distributors: List the names and addresses of all distributors who sold cigarettes or roll-your-
own products fabricated by the tobacco product manufacturer named in Part 2 into Oregon in
2018 or 2019:
Part 7: PACT Act Compliance
Attach a copy of Applicant’s PACT Act Registration filed with the U.S. Department of
Justice and the Oregon Department of Revenue.
The Applicant certifies that:
The Applicant is in compliance with all reporting obligations to the State of Oregon; or
The Applicant does not ship tobacco products directly into the State of Oregon. Attach
a list of Oregon-licensed distributors that Applicant sells tobacco products to.
Part 8: Execution by Authorized Designee
The undersigned certifies that as of the date of this Certification, the above-named Applicant is
a Participating Manufacturer under the Tobacco Master Settlement Agreement as defined in ORS
180.405 (6).
Under penalty of perjury, I certify and declare that all of the statements and information
contained in this Certification, including but not limited to any accompanying statements or
attachments herewith, are true, correct, accurate and complete in every particular, and that I am
a person authorized to bind the Tobacco Product Manufacturer making this Certification either
under the laws of the State of Oregon or of the jurisdiction where the manufacturer resides or is
organized. Any violation of the requirements of ORS 323.800 to 323.806 or ORS
180.400 to 180.455 is a basis for removal of the applicant’s Brands from Oregon’s
Directory of compliant Tobacco Product Manufacturers.
** This Certification must be signed and dated before an authorized notary public**
Signature of Authorized Person:
Date:
Printed Name of Authorized Person:
Title:
Subscribed and sworn to or affirmed before me on this date:
Signature of Notary Public:
City or County of:
Seal of Notary Public: My Commission Expires:
Mail the completed original Participating Manufacturer’s Certification and all supporting
documents to:
Office of the Attorney General for the State of Oregon
Oregon Department of Justice
Civil Enforcement Division; Attn: Tobacco Enforcement
1162 Court Street, NE
Salem, OR 97301-4096
Participating Manufacturer Certification
DM#6326172-V5 (Revised: 04-06-2020) Page 4 of 4
ALTERNATIVE EXECUTION
BY AUTHORIZED DESIGNEE
Declaration made within the United States
The undersigned certifies that as of the date of this Certification, the above-named Applicant is
a Participating Manufacturer under the Tobacco Master Settlement Agreement as defined in ORS
180.405 (6).
Under penalty of perjury, I certify and declare that all of the statements and information
contained in this Certification, including but not limited to any accompanying statements or
attachments herewith, are true, correct, accurate and complete in every particular, and that I am
a person authorized to bind the Tobacco Product Manufacturer making this Certification either
under the laws of the State of Oregon or of the jurisdiction where the manufacturer resides or is
organized. Any violation of the requirements of ORS 323.800 to 323.806 or ORS 180.400
to 180.455 is a basis for removal of the applicant’s Brands from Oregon’s Directory of
compliant Tobacco Product Manufacturers.
I hereby declare that the above statement is true to the best of my knowledge and belief, and
that I understand it is made for use as evidence in court and is subject to penalty for perjury
Signature of Authorized Person:
Date:
Printed Name of Authorized Person:
Title:
Declaration made outside the boundaries of the United States
The undersigned certifies that as of the date of this Certification, the above-named Applicant is
a Participating Manufacturer under the Tobacco Master Settlement Agreement as defined in ORS
180.405 (6).
Under penalty of perjury, I certify and declare that all of the statements and information
contained in this Certification, including but not limited to any accompanying statements or
attachments herewith, are true, correct, accurate and complete in every particular, and that I am
a person authorized to bind the Tobacco Product Manufacturer making this Certification either
under the laws of the State of Oregon or of the jurisdiction where the manufacturer resides or is
organized. Any violation of the requirements of ORS 323.800 to 323.806 or ORS
180.400 to 180.455 is a basis for removal of the applicant’s Brands from Oregon’s
Directory of compliant Tobacco Product Manufacturers.
I declare under penalty of perjury under the laws of Oregon that the foregoing is
true and correct, and that I am physically outside the geographic boundaries of the
United States, Puerto Rico, the United States Virgin Islands, and any territory or
insular possession subject to the jurisdiction of the United States.
Executed on the (day) of (month), (year) at (city or other
location), (country).”
Signature of Authorized Person:
Date:
Printed Name of Authorized Person:
Title:
(day)
(month)
(year)
(city or other location)
(country)
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Form 20: State of Oregon Participating Manufacturer Certification (Columbia Gorge Community College)

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Completed 15 August 2020

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