Kentucky Certification of Tobacco Product Manufacturers

PLEASE PRINT Date………….SURNAME(S):__________________________________FIRST NAME(S):________________________________ADDRESS:_______________________________________________________________________________________________________________POSTCODE:_______TELEPHONE:_________________FAX:____________MOBILE:_____________________________________E-MAIL ADDRESS:__________________________________________________________________________INTRODUCEDBY:______________________________________PLEASE PRINT THE NAME OF THE CENTRALCOASTLETS MEMBER WHO REFERRED YOU.Please return this form with membershipfee (or contact us for bank details fordirect deposit) to:30/10/2008Central Coast LETSPO Box 3151Umina Beach NSW 2257OFFICE USE ONLY:MembershipApplicationAccount Trading No: ……… Date: …………Membership fee: ………………cash/cheq/DDEntered by: …………………………………..*Refer a friend to LETS and earn 10 ShellsPLEASE PRINTDirectoryInformationGOODS/SERVICES I WISH TO OFFER:……………………………………………………………….……………………………………………………………….……………………………………………………………….……………………………………………………………….GOODS/SERVICES I AM REQUESTING:……………………………………………………………….……………………………………………………………….…………………………………………………………….……………………………………………………………..If you are interested in helping theCentralCoastLETS ‘Committee’ please writedown your skills detailing (collating, typing,event organisation, willing worker, etc)……………………………………………………………….……………………………………………………………….NOTE: CentralCoastLETS Committee will be defined as any member whovoluntarily attends a scheduled members’ meeting or undertakes tasksrelevant to the functioning of the LETSystem.Membership and Renewal FeesSince LETS is not for profit, charges are kept to a minimum.Annual membership to cover administration costs:If you join in July, August or September the fee is $20 plus 20shells. Or $10 and 20 Shells depending on what you feel youcan afford.If you join in October, November or December the fee is $15plus 15 shells. Or $10 and 15 Shells depending on what youfeel you can afford.If you join in January, February or March the fee is $10 plus10 shells.If you join in April, May or June the fee is $5 plus 5 shells.(Shell's will be automatically debited from your account).(Fees subject to change).Conditions ofMembershipConditions of Membership1. Central Coast LETS is a non-profit organisation managed by a workinggroup made up of members. LETS provides a service which allowsmembers to exchange information to facilitate trading and maintain suchrecords of that trading as members request.2. A "Shell" is the symbol of energy transferred between members. Membersmust be willing to trade in Shells.3. Members will transfer Shells from one members account to that of anotheronly on the authority of the member receving the item/service.4. Central Coast LETS is authorised to levy charges on members accounts inShells at a rate determined by Central Coast LETS.5. Central Coast LETS may decline a transaction or a membership itconsiders inappropriate.6. Accountability of taxes incurred by members is the obligation of thoseinvolved in an exchange. Central Coast LETS has no obligation norliability to report to the Australian Taxation Office nor collect taxes on theirbehalf.7. No warranty or undertaking as to the value, condition or quality of the itemsexchanged is expressed or implied by the virtue of introduction ofmembers to one another.8. While all information on members accounts, except balance and turnover,is considered personal and confidential, LETS cannot guaranteeconfidentiality nor be held liable for breach of it. A member may know thebalance and turnover of another member.9. Central Coast LETS may act on behalf of members in seeking satisfactionfrom a member whose account is heavily out of balance.10. All transactions between members are the sole responsibility of thosemembers and no liability to the members of any nature shall be incurred byCentral Coast LETS in respect of such a transaction.11. Central Coast LETS requests that members make every reasonable effortto bring their account to a zero balance before leaving the system.12. No member shall be entitled to claim for any loss, damage or injurysuffered by any other member and Central Coast LETS expressly disclaimssuch liability.PLEASE READ THESE CONDITIONS CAREFULLY, SIGN WHERE SHOWNBELOW AND RETURN TO CENTRALCOASTLETS.In consideration of CentralCoastLETS accepting me/us asmember/s, I/we agree to be bound by the above Conditionsof Membership:Signed: ………………………………………………………………………………………………………………

Commonwealth of Kentucky-Tobacco Product Manufacturer CertificationPart 1:Tobacco Product Manufacturer IdentificationCompany: ____________________________________________________________________________________Address: ____________________________________________________________________________________Phone: _________________________________________ FAX __________________________________Email: _________________________________________Name/Title of Person Completing Report: _______________________________________________________________The Tobacco Product Manufacturer identified above is, as of the date of this Certification (Initial One):________A Participating Manufacturer under the Tobacco Master Settlement Agreement________ A Non-Participating Tobacco Product Manufacturer in full compliance with KRS 131.602Part 2:Sales YearYear of Sales for this Certificate of Compliance is: (Complete a separate certification for each year of sales)______________Part 3:Brand Family Identification (Attach additional Sheets if Necessary)Participating Manufacturers complete A & B; Non-Participating Manufacturers complete A through E.Samples of labels and packaging for each brand are required, as well as copies of manufacturing permits/licenses,trademark documentation, current federal approval letters, fire safe certification and PACT act registration(unless already on file).(Note: Nine-hundredths of an ounce (.09) of RYO tobacco counts as 1 cigarette).A. BrandFamily1B. BrandNameC. UnitsSoldPrecedingYrD. UnitsSoldCurrentYrE. Manufacturer (includefull address informationfor each location)F. List KY licensedstampers and amountssold by brand.(Use additional or separate sheets if necessary.)1 Indicate with an asterisk (*) those brands that will not be sold in the current year.

Part 4:Non-Participating Manufacturer InformationA. Registered Agent in Kentucky for service of process (provide proof of acceptance/ appointment)Agent Name: ____________________________________________________________________________________Company: ____________________________________________________________________________________Address: ____________________________________________________________________________________Phone: _________________________________________ FAX __________________________________B. Qualified Escrow Fund – Financial Institution (provide copy of escrow agreement if not on file)Name of Institution: ______________________________________________________________________________Address:______________________________________________________________________________Representative Name: ________________________________________ Phone: ______________________________Escrow Acct No: ________________________________________ State Account No: _____________________C. Escrow Deposit/Withdrawal History for KentuckyDate Deposit Withdrawal2 BalancePart 5.Execution by Authorized Designee (all manufacturers)Under penalty of perjury, I, as authorized agent of the manufacturer, state that the information contained in thisCertification is true and accurate.Designee (Print Name): ________________________________________Signature of Designee: ________________________________________Title: _______________________Date: _______________________Subscribed and sworn to before me on this date: ___________________________________________________Signature of Notary Public: _____________________________________ City or County of_____________________My Commission expires: ________________________________________Mail the completed certificate of compliance to:Office of Attorney General700 Capitol Avenue, Suite 118Frankfort, KY 40601Attn: Michael Plumley, Assistant Attorney General2 Withdrawals must comply with KRS 131.602. Verification of compliance must be provided.