Packaging Change Certification
DM#9220884 (Revised: 10-15-2018) Page 1 of 1
State of Oregon
Packaging Change Only
Part 1: Manufacturer Identification
Applicant Company Name: FEIN No.
Mailing Address:
City: State: Zip: Country:
Phone: Fax: Email:
Name of Person Completing Certification:
Part 2: Manufacturing Facility Information
Plant Name:
Physical Address:
City: State: Zip: Country:
Plant Phone: Plant Fax:
Name/Title of Person at Plant (if different than above):
Part 3: Brand Family and Brand Style Identification
Brand Family and Brand Styles: Please list each currently certified brand style that has
packaging changes below. Please provide the original packaging that has changed or promotional
packaging. We will also accept an electronic color copy if it includes views of each side of the packaging and
the UPC is clearly visible. If an electronic color copy is provided, please also provide an affidavit that the
artwork represents how the product will appear on store shelves.
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.
Signature of Authorized Person: Date:
Printed Name of Authorized Person: Title:
Return to:
Office of the Attorney General for the State of Oregon
Oregon Department of Justice
Civil Enforcement Division; Attn: Tobacco Enforcement
1162 Court Street, NE
Salem, OR 97301-4096
