Fillable State of Oregon Manufacturer Certification For Listing on (Columbia Gorge Community College)

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State of Oregon Manufacturer Certification For Listing on (Columbia Gorge Community College)

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Smokeless Tobacco Manufacturer Certification Page 1 of 4
DM #2346075-V3 (Revised: 04-06-2020)
State of Oregon
Manufacturer Certification
For Listing on the Oregon Smokeless Tobacco Directory
Part 1: Year and Type of Certification
Year for this Certification: 20
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:
Plant Phone: Plant Fax:
Name/Title of Person at Plant (if different than above):
Part 4: 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 brand style (those brand styles that will not be sold in the current
year should be marked with an asterisk (*)).
Moist Snuff or Chewing Tobacco: Indicate whether the product is moist snuff or chewing tobacco.
B. Additional Information: Check the appropriate box(es):
Initial or Supplemental Certification: Included with this Certification is corresponding actual moist
snuff or chewing tobacco packaging (without tobacco) for each Brand Style for which Applicant requests
certification.
Annual Certification – No Packaging Changes: Corresponding actual moist snuff or chewing
tobacco 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
moist snuff or chewing tobacco packaging (without tobacco) is included.
Part 5: Manufacturer Status
The Manufacturer listed in Part 2 of this application is (check one):
A participating manufacturer, under the Smokeless Master Settlement Agreement. Do not complete
Parts 6, 7, or 8 of this application.
An escrow-exempt manufacturer, pursuant to the Master Settlement Agreement or other relevant
settlement agreement. Do not complete Parts 6, 7, or 8 of this application.
A nonparticipating manufacturer, as defined in ORS 180.468(2). Complete all parts of this
application.
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Smokeless Tobacco Manufacturer Certification Page 2 of 4
DM #2346075-V3 (Revised: 04-06-2020)
Part 6: Non-Participating Manufacturer’s Certification and Election under ORS 323.816
The Manufacturer listed in Part 2 of this application certifies that it is in full compliance with ORS 323.816, by
electing to (check one):
(except for section III(m)) and VII of the Smokeless Tobacco Master Settlement Agreement. (Do not
complete Part 7. Complete Parts 8 and 9 of this application).
$0.40 per unit sold for 2010 or such amount adjusted for inflation for each year thereafter. (Complete
all parts of this application)
Part 7: Qualified Escrow Fund and Financial Institution
The Applicant certifies that at the time of this Certification, the Applicant has:
Oregon.
fund complies with ORS 323.810 to 323.816.
for the State of Oregon and that governs the Qualified Escrow Fund for the State of Oregon. A copy of
the current Qualified Escrow Agreement, including any amendments, is attached.
in a separate segregated account, separate and apart from escrow funds held on behalf of any other
beneficiary.
party.
the last year and attached proof of the current escrow account balance from the Escrow Agent.
Name of Financial Institution Phone No.
Contact Agent Name Fax No.
Mailing Address:
Escrow Account No. Oregon Sub-Acct. No.
Part 8: Registered Agent/Approved Agent for Service of Process
The Applicant (check one):
appointment to the Attorney General for the State of Oregon by submitting a completed Non-
Participating Manufacturer’s Appointment of Registered Agent for State of Oregon and
Registered Agent’s Statement, which can be found at www.doj.state.or.us
Smokeless Tobacco Manufacturer Certification Page 3 of 4
DM #2346075-V3 (Revised: 04-06-2020)
Part 9: Execution by Authorized Agent
Under penalty of perjury, I certify 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 323.810 to 323.816 or ORS 180.465 to 180.494
is a basis for removal of the Applicant’s Brand Families from the Oregon Directory of Compliant
Smokeless Tobacco Product Manufacturers and Brands.
The Applicant/Tobacco Product Manufacturer hereby submits itself to the jurisdiction of the Circuit Court of the
County of Marion, Oregon, for purposes of all litigation arising out of this certification or the sale of smokeless
tobacco products in Oregon.
*
** 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: County of:
Seal of Notary Public: My commission expires:
Mail the completed original Non-Participating Manufacturer’s Certification and all supporting documents to:
O
ffice of the Attorney General
Oregon Department of Justice
Civil Enforcement Division: Tobacco Enforcement
1162 Court Street NE
Salem, OR 97301
Smokeless Tobacco Manufacturer Certification Page 4 of 4
DM #2346075-V3 (Revised: 04-06-2020)
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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State of Oregon Manufacturer Certification For Listing on (Columbia Gorge Community College)

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Completed 15 August 2020

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