Packaging Change Certification Form

Complete all fields or indicate N/A – Do not leave blanks.
Please review all instructions for further information.
Failure to provide all necessary information will result in the rejection of your certification.

PART I:

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Number

Fax Number

Factory Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Designated Contact

First Last

Name of Legal Counsel for cc (optional)

First Last

Email Address Designated to Accept All Official Communication

Legal Counsel Email Address

Company Website Address

Verify that all currently held information is correct and has not changed or expired.

Yes
No

Please attach updated documentation.

Drop files here or

Max. file size: 100 MB.

PART II:

Brand Family Identification (attach additional sheets if necessary) Provide an electronic color copy of every brand style or promotional packaging that has changed. Include views of each side of the packaging with UPC clearly visible.

Section A. Brands Currently Certified and on the Directory with packaging changes

List brands and styles with packaging changes

Brand	Style	Flavor	Filter/Non	Package

File Upload

Drop files here or

Max. file size: 100 MB.

PART III: Execution by Corporate Officer or Director

I understand that any violation of the requirements of the Tobacco Product Manufacturer Directory Act of the Tobacco Settlement Agreement Act of 2000 is a basis for removal of the manufacturer’s brand families from the Commonwealth’s Directory of Approved Brands.

I agree that all packaging images submitted with this certification are free of proprietary and confidential information and may be publicly posted on the Pennsylvania Tobacco Product Directory website.

I hereby certify and declare under penalty of perjury that all of the statements and information contained in the certification, including but not limited to any accompanying statements or attachments herewith, are true, correct and complete and that I am a person authorized to bind the Tobacco Product Manufacturer making this certification either under the laws of the Commonwealth of Pennsylvania or of the jurisdiction where the manufacturer resides or is organized.

Signature

Print Name

Title