STATE OF ARIZONA
Office of the State Fire Marshal
1110 W Washington St, Suite 100
Phoenix, Arizona 85007
(602) 364-1003 FAX (602)364-1052
FSG.OFM@DFBLS.AZ.GOV
FIRE STANDARDS COMPLIANT (FSC)
CIGARETTE CERTIFICATION FORM
Cigarettes must be tested according to Arizona Revised Statutes §§ 41-2170 through 41-2170.08 and all rules promulgated thereunder.
separate Fire Standards Compliant Ci
arette Certification Form
FSC-2
must be completed if a ci
arette manufacturer emplo
s more than one
testing entity to conduct FSC cigarette testing or if certifications for any brand styles are sought at different times. Please print additional pages
of the Certification by Cigarette Variety form (FSC-2A) as necessary.
MANUFACTURER
NAME
CONTACT PERSON PHONE NUMBER
TESTING
TESTING ENTITY
LABORATORY OR TESTING ENTITY'S NAME CONTACT PERSON
ADDRESS CITY STATE ZIP CODE
PHONE NUMBER FAX NUMBER
E-MAIL ADDRESS (optional) WEB ADDRESS (optional)
TEST METHOD
ASTM E2187-04 Alternate method approved by the Arizona State Fire Marshal. Attach a copy of the Arizona State Fire Marshal’s
authorization of the proposed testing method.
TESTING AND QUALITY ASSURANCE PROGRAM
ISO/IEC 17025 ACCREDITED REPEATABILITY ABOVE 0.19 TESTED ON 10 LAYER PERFORMANCE STANDARD
OF FILTER PAPER MET*
YES YES YES YES
NO NO NO NO
SIGNATURE
By my signature, I verify that the information on this form, the attachments and related forms is true. I understand that knowingly providing a false certification
of fire standard compliant cigarettes is a violation of Arizona law and may be subject to civil and criminal penalties.
ORIGINAL SIGNATURE OF QUALITY ASSURANCE DIRECTOR DATE
QUALITY ASSURANCE DIRECTOR (please print)
FSC-2 05/09
