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
FSC.OFM@DFBLS.AZ.GOV
APPLICATION FOR FIRE STANDARD COMPLIANT CIGARETTE APPROVAL BY
MANUFACTURER
This application must be accompanied by all fees, documents and information required by Arizona Revised Statutes §§ 41-2170 through 41-2170.08
and all rules promulgated thereunder. Please complete this form in its entirety. All fees are non-refundable except as determined by the Arizona
State Fire Marshal.
APPROVAL
CHECK ONE TYPE OF APPROVAL
APPROVAL FEE QUANTITY OF BRAND FAMILIES
TOTAL INCLUDED
INITIAL APPROVAL
$250 per each brand family
$
3 YEAR RENEWAL*
$250 per each brand family
$
MANUFACTURER
COMPANY NAME CONTACT PERSON FEDERAL EMPLOYER
IDENTIFICATION NUMBER (FEIN)
ADDRESS
CITY
STATE ZIP CODE
PHONE NUMBER FAX NUMBER
E-MAIL ADDRESS (optional) WEB ADDRESS (optional)
In applying for fire standard compliant cigarette approval, I certify that the cigarette varieties listed on FSC Certification Forms FSC-2 and FSC-2A that are
submitted together or separately in conjunction with this application comply with Arizona Revised Statutes §§ 41-2170 through 41-2170.08 and all rules
promulgated thereunder. By my signature, I verify that the information on the application and all related forms and/or attachments 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 AUTHORIZED REPRESENTATIVE OF MANUFACTURER DATE
PRINTED NAME TITLE
CHECK LIST (All of the following items must accompany this document for the application to be complete):
APPROPRIATE FEE FIRE STANDARDS COMPLIANT MARKING APPROVAL FORM AND
CIGARETTE CERTIFICATION FORM ILLUSTRATION OF PROPOSED MARKING
PAGES _________ TO _________
PLEASE SUBMIT FORMS THROUGH E-MAIL TO : FSC.OFM@DFBLS.AZ.GOV
OR Mail them to: ARIZONA STATE FIRE MARSHAL FSC PROGRAM
1110 W.WASHINGTON - SUITE 100
PHOENIX, AZ 85007
* Required every three years from ti date of laboratory tes
FSC-1 05/09
