OREGON – Page 1 DM #5869821 (2/12/2018)
QUARTERLY BRAND SPECIFIC REPORT FOR SMOKELESS TOBACCO PRODUCTS
PRODUCTS WITH OREGON TAX PAID FOR ALL MANUFACTURERS
Part 1: Company Information and Reporting Period
For the ________________ QUARTER OF 20_______
LICENSE NO:_____________________________ (FEIN):
Business Name:
Physical Address:
Mailing Address:
Phone No.:____________________________________ Fax No.:
Email:
Name of Person Completing Form:
Phone and Email of Person Completing Form:
Part 2: Sales Information and Certification
You Must Check at Least One Box:
□ No sales to Report this quarter.
□ Sales of smokeless tobacco products are shown in Section 3.
□ Section 3 submitted electronically. (Original page 1 with signature will be mailed).
Under penalties of false swearing, I declare that I have examined this report, and any additional
reports submitted in written or electronic form, and to the best of my knowledge and belief the
information provided is true, correct, and complete.
Print Name Date
X
Signature of Distributor or Representative Title
PLEASE REFER TO OREGON’S DIRECTORY
OF SMOKELESS TOBACCO BRANDS
APPROVED FOR SALE IN OREGON AT
www.doj.state.or.us/tobacco FOR THE
CORRECT TOBACCO BRAND
MANUFACTURER.
This form is due 20 days after the close of the
reporting quarter.
Please return completed form to:
State of Oregon
Department of Justice
Civil Recovery – Tobacco Enforcement
1162 Court Street NE
Salem, OR 97301-4096
Email: tobaccoenforcementBSR@doj.state.or.us
**** ELECTRONIC SUBMISSION***
For information on submitting Part 3 and Part 4
electronically, contact the tobacco unit at:
tobaccoenforcementBSR@doj.state.or.us
