Fillable State of Oregon Non-Participating Manufacturer Certification For Listing (Columbia Gorge Community College)

Fill Online, Printable, Fillable, Blank State of Oregon Non-Participating Manufacturer Certification For Listing (Columbia Gorge Community College) Form

Use Fill to complete blank online COLUMBIA GORGE COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

State of Oregon Non-Participating Manufacturer Certification For Listing (Columbia Gorge Community College)

On average this form takes 33 minutes to complete

The State of Oregon Non-Participating Manufacturer Certification For Listing (Columbia Gorge Community College) form is 7 pages long and contains:

  • 0 signatures
  • 47 check-boxes
  • 111 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Columbia Gorge Community College

BROWSE COLUMBIA GORGE COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Non-Participating Manufacturer Certification Page 1 of 7
DM#6326535-V4 (Revised: 04-06-2020)
State of Oregon
Non-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:
Plant Phone: Plant Fax:
Name/Title of Person at Plant (if different than above):
Part 4: Status as a Tobacco Product Manufacturer
The undersigned certifies that as of the date of this Certification, the above-named
applicant is a Non-Participating Tobacco Product Manufacturer in full compliance with ORS
323.800 to 323.806, including having made all required payments into a Qualified Escrow Fund
as defined in ORS 323.800(6). The Applicant qualifies as a Non-Participating Tobacco Product
Manufacturer because (check all that apply):
The Applicant is the fabricator of the listed brands in this Certification which are
intended to be sold in the United States including Cigarettes and RYO intended to be
sold in the United States through an importer.
The Applicant is the first purchaser anywhere for resale in the United States of
Cigarettes and RYO manufactured anywhere that the manufacturer does not intend to
be sold in the United States. If yes, provide the name, address, plant address, contact
person, phone and fax number of the fabricator.
The Applicant is a successor of any entity described above (i.e. manufacturer/first
importer)
Part 5: 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 Applicant’s 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.
Print
Reset
Non-Participating Manufacturer Certification Page 2 of 7
DM#6326535-V4 (Revised: 04-06-2020)
Part 6: 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 (*)).
Cigarette or RYO: Indicate whether the product is a cigarette or RYO.
Units Sold – Prior Year: Indicate the number of units sold during the prior calendar year.
Units Sold – Current Year: Indicate the number of units sold during the current calendar year
from January 1 to date of application.
Current Manufacturer: Include the name and address of the current manufacturer.
Prior Manufacturer(s): Include the name and address of all prior manufacturers.
Current Trademark Holder: Include the name and address of the current trademark holder.
Prior Trademark Holder: Include the name and address of all prior trademark holders.
B. Additional Information: Check the appropriate boxe(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 request
s
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.
Non-Participating Manufacturer Certification Page 3 of 7
DM#6326535-V4 (Revised: 04-06-2020)
Part 6 B. Additional Information, Continued.
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.
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 ORS 323.800 to 323.806 (Escrow Statutes)
.
Part 7: Organizational Documents
A. Organizational Documents – Initial / Annual / Supplemental Certification:
No Changes to Organization Documents: Organizational documents were previously
provided with a prior year’s Certification Application and there have been no changes. Proceed to
Part 8 of this application.
Organizational Documents Have Changed: There have been changes to the organizational
documents previously submitted. Complete the rest of Part 7 and provide copies of all updated
documents as follows:
B. Additional Information: Check the appropriate box(s):
Check one:
Response
Provided
Does
Not
Apply
Attach the following documents or information:
Partnership or Association: Current copy of the Certificate of Partnership or the
certificate required to be filed by any state, county or municipality.
Corporation: 1) Current copy of the Certificate of Incorporation or other charter and
2) extracts of documents listing the officers authorized to sign for the company.
LLC or other entity: Current copy of the business document(s) filed with a state,
county, or municipal entity when such filing is required. Include copy of any
document indicating persons authorized to sign for the entity.
Company Officers/Owners: Provide a list of all company officers and company
owners (all persons with an equity interest of 10% or more in the company). Include
name, address, phone number and email address.
Affiliates: Provide a list of all company Affiliates (DEFINE) that also manufacture,
import, distribute, or sell cigarettes or RYO. Include the name, address and contact
information for each Affiliate.
Marketing Information: For each brand family, list the name, address and contact
information for each Oregon distributor and Wholesaler through which Applicant
intends to sell cigarettes or RYO in Oregon.
Agreements with Participating Manufacturers: Identify every agreement
between Applicant and any Participating Manufacturer (“PM”) or PM Affiliate that
relates to the making, importing, distribution, transportation, or sale of each Brand
Family.
Non-Participating Manufacturer Certification Page 4 of 7
DM#6326535-V4 (Revised: 04-06-2020)
Part 7B: Additional Information, Continued.
Agreements Regarding Compliance with the Qualified Escrow Statute: List
every Brand Family that is the subject of any agreement regarding compliance with a
Qualified Escrow Statute.
Part 8: 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.
Part 9: Bond Information
A. Amount of Bond: $__________________.
Bond must be the greater of Twenty-Five
Thousand Dollars ($25,000) or the highest amount of escrow owed in Oregon by the Non-
Participating Manufacturer or its predecessor in the last 12 quarters.
B. Bonding Company:
Agent Name: Company:
Mailing Address:
City:
State:
Zip:
Country:
Phone:
Fax:
Email:
Attach copy of NPM Surety Bond
Part 10: Distributors and Importer
The applicant identified in Part 2 affirms that all shipments or sales made into Oregon by the
applicant or its importer are made to a distributor of cigarettes licensed under ORS 323.105
or a distributor of tobacco products licensed under ORS 323.530.
A. Distributors:
List the names and addresses of all distributors who sold cigarettes or roll-
your-own products fabricated by the non-participating tobacco product manufacturer named
in Part 2 into Oregon in 2018 or 2019:
B. Importer information: If NPM is located outside of the United States, provide the following
importer information:
Importer: Contact Name:
Mailing Address:
City:
State:
Zip:
Country:
Phone:
Fax:
Email:
TI Permit No: FEIN No:
YES NO Check Yes or No as appropriate to ALL questions.
Is Importer in compliance with all reporting and registration requirements of
the PACT Act, 15 U.S.C § 376.
Does Importer accept joint and several liability with the non-participating
manufacturer for all escrow obligations, as well as payment of all civil
penalties, and reasonable costs and expenses of prosecution for failure of to
deposit escrow obligations?
Does Importer consent to personal jurisdiction in Oregon for purposes of claims
by the state with regard to escrow obligations?
Non-Participating Manufacturer Certification Page 5 of 7
DM#6326535-V4 (Revised: 04-06-2020)
Part 10: Distributors and Importer, Continued.
Has Importer appointed a registered agent for service of process?
Attach copy of United States Importer Declaration
Part 11: Qualified Escrow Fund and Financial Institution
The Applicant certifies that at the time of this Certification, the Applicant has:
Enclosed the completed Annual Escrow Compliance Certificate and Affidavit for the prior
year’s sales in Oregon.
Established and continues to maintain a Qualified Escrow Fund as defined in ORS 323.800(6)
and said fund complies with ORS 323.800 to 323.806.
Executed a Qualified Escrow Agreement that has been reviewed and approved by the
Attorney General 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.
Ensured that the escrow funds held in the Qualified Escrow Fund on behalf of the State of
Oregon are in a separate segregated account, separate and apart from escrow funds held on
behalf of any other beneficiary.
Ensured that the Qualified Escrow Fund is not encumbered by a security interest granted to a
third party.
Attached information documenting all deposits and withdrawals from the Qualified Escrow
Fund during 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 12: Registered Agent/Approved Agent for Service of Process
The Applicant has (check one):
Is registered to business in the State of Oregon; or
Has appointed a resident agent for service of process in the State of Oregon and provided
notice of the 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
Part 13: Disclosures
YES NO
Check Yes or No as appropriate to ALL questions. Provide additional
information where requested.
Within the past two (2) years, there has been a change in manufacturer
(fabricator) of one or more of the Brand Families listed in this Certification? If
yes, provide details of the change.
Has any state obtained a court judgment or administrative order against the
Applicant relating to the Brand Families listed in this Certification? If yes, list
the location, case number and date of the judgment or order and the Brand
Families involved.
As of the date of this Certification, has Applicant satisfied all court judgments
and orders to pay penalties in any state, related to Brand Families listed in this
certification?
Non-Participating Manufacturer Certification Page 6 of 7
DM#6326535-V4 (Revised: 04-06-2020)
Part 13: Disclosures, Continued.
Has Applicant or any Person or Affiliate listed in Part 7 had any of its cigarettes
or RYO banned, enjoined from sale or removed from a tobacco directory of any
state for any reason? If yes, list: a) the Brand Families at issue, b) location of
the determination.
Has Applicant or any Person or Affiliate listed in Part 7 been convicted of a
crime under federal, state or foreign laws in connection with the sale of
cigarettes or RYO? If yes, provide details.
Has Applicant or any Person or Affiliate listed in Part 7 been denied a permit,
license or other authorization to engage in any business relating to the sale of
tobacco by any government entity (federal, state, local or foreign) or had such
permit revoked, suspended, or otherwise terminated? If yes, provide details.
Is Applicant or any of the Person or Affiliate listed in Part 7 entitled to claim
Sovereign Immunity based on Tribal Status? If yes, provide information
regarding tribal status and affiliation.
Part 14: 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 323,800 to 323.806 or ORS 180.400 to 180.455 is a basis for removal of
the Applicant’s Brand Families from the Oregon Directory of Compliant 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 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
Non-Participating Manufacturer Certification Page 7 of 7
DM#6326535-V4 (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)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

State of Oregon Non-Participating Manufacturer Certification For Listing (Columbia Gorge Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document