"Fire Standards Compliance Certification Form" - Kansas

Fire Standards Compliance Certification Form is a legal document that was released by the Kansas Attorney General's Office - a government authority operating within Kansas.

Form Details:

  • Released on March 3, 2015;
  • The latest edition currently provided by the Kansas Attorney General's Office;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kansas Attorney General's Office.

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F
S
C
IRE
TANDARDS
OMPLIANCE
C
F
ERTIFICATION
ORM
K
S
F
M
ANSAS
TATE
IRE
ARSHAL
R
M
3, 2015
EVISED
ARCH
T
C
YPE OF
ERTIFICATION
0
This certification is:
Initial
Supplemental
3-Year Renewal
M
I
ANUFACTURER
NFORMATION
Manufacturer:
____________________________________________________________
Mailing Address:
____________________________________________________________
____________________________________________________________
Street Address:
____________________________________________________________
____________________________________________________________
The street address is the physical location of the manufacturing plant.
Phone Number:
________________________
Fax Number: ___________________
E-Mail Address:
____________________________________________________________
Website:
____________________________________________________________
Federal Taxpayer
ID Number:
____________________________________________________________
Only applies if manufacturer is registered in the United States.
Fire Standards Compliance Certification Form
Revised March 3, 2015
Page 1 of 5
F
S
C
IRE
TANDARDS
OMPLIANCE
C
F
ERTIFICATION
ORM
K
S
F
M
ANSAS
TATE
IRE
ARSHAL
R
M
3, 2015
EVISED
ARCH
T
C
YPE OF
ERTIFICATION
0
This certification is:
Initial
Supplemental
3-Year Renewal
M
I
ANUFACTURER
NFORMATION
Manufacturer:
____________________________________________________________
Mailing Address:
____________________________________________________________
____________________________________________________________
Street Address:
____________________________________________________________
____________________________________________________________
The street address is the physical location of the manufacturing plant.
Phone Number:
________________________
Fax Number: ___________________
E-Mail Address:
____________________________________________________________
Website:
____________________________________________________________
Federal Taxpayer
ID Number:
____________________________________________________________
Only applies if manufacturer is registered in the United States.
Fire Standards Compliance Certification Form
Revised March 3, 2015
Page 1 of 5
D
C
ESIGNATED
ONTACT
Identify the person that you wish to receive all correspondence and official notifications. Failure to
designate an official contact person will result in an incomplete certification.
Contact Name:
____________________________________________________________
Organization:
____________________________________________________________
Relationship to
Manufacturer:
____________________________________________________________
E.g., Attorney, Importer, Tax Compliance Manager, etc.
Mailing Address:
____________________________________________________________
____________________________________________________________
Phone Number:
________________________
Fax Number: ___________________
E-Mail Address:
____________________________________________________________
A
S
P
GENT FOR
ERVICE OF
ROCESS
Agent:
____________________________________________________________
Mailing Address:
____________________________________________________________
____________________________________________________________
Phone Number:
________________________
Fax Number: ___________________
E-Mail Address:
____________________________________________________________
Important Notice: Pursuant to K.S.A. 31-601 et seq., manufacturer must identify an agent for
service of process by filing a Tobacco Product Manufacturer Appointment of Agent for Service of
Process Form, along with a $35.00 fee, to the Kansas Secretary of State’s Office. The form is
available at www.ksag.org/tobacco.
Fire Standards Compliance Certification Form
Revised March 3, 2015
Page 2 of 5
CIGARETTE CERTIFICATION
Complete the chart below identifying each cigarette brand variety that manufacturer wishes to certify as Fire Standards Compliant in Kansas. Attach additional
sheet(s) as needed. Manufacturer may submit the following in an alternate format provided it includes all the requested information below.
Important Note: Manufacturer must pay a certification fee of $250.00 for each cigarette brand variety included in this certification.
Brand Family
Style
Length
Circumf
Identifying Name of
Menthol
Filter or
Hard
Testing
New
Renew
Remove
(mm)
-erence
Cigarette Brand Variety
Non-
Pack or
Date
(mm)
According to Manufacturer
Filter
Soft Pack
Fire Standards Compliance Certification Form
Revised March 3, 2015
Page 3 of 5
T
M
ESTING
ETHOD
BRAND VARIETIES OVERVIEW
Provide the total number of brand varieties you are certifying today:
__________
Provide the total number of new brand varieties (if any):
__________
Provide the total number of brand varieties you wish to remove (if any):
__________
T
M
ESTING
ETHOD
Each cigarette brand variety included in this certification must be tested in accordance with K.S.A.
31-603. Pursuant to K.S.A. 31-603(e) our office is requesting that you attach to this certification a copy of the
official test results.
T
M
(Check appropriate box below.):
ESTING
ETHOD
American Society of Testing and Materials (“ASTM”) Standard E2187-04.
Alternate method approved by the Kansas State Fire Marshal.
S
D
UPPLEMENTAL
OCUMENTATION
Provide the following documents with this certification form:
Certification Fee
Provide payment of $250.00 for each cigarette brand variety included in this certification.
Checks must be made payable to the Kansas State Fire Marshal. Arrangements may also be
made for the electronic transfer of funds.
Identification of Agent for Service of Process to Kansas Secretary of State
Provide a copy of an executed Tobacco Product Manufacturer Appointment of Agent for
Service of Process Form that was filed with the Kansas Secretary of State’s Office.
Packaging Samples
Provide an illustration (or packaging sample) that identifies the location of the required
“FSC” mark on manufacturer’s cigarette packaging. Digital samples are preferred.
Testing Records
Provide records verifying that each cigarette brand variety included in this certification has
been tested and complies with fire safety standards pursuant to K.S.A. 31-601 et seq.
Fire Standards Compliance Certification Form
Revised March 3, 2015
Page 4 of 5
V
C
ERIFICATION OF
ERTIFICATION
I attest that, to the best of my knowledge, all of the information contained in this certification and
any attachments is true, correct, and complete. I am authorized, under the laws of the state of
Kansas or the jurisdiction where the manufacturer resides or is organized, to bind the manufacturer
making this certification.
I attest that each cigarette brand variety included in this certification has been tested in accordance
with K.S.A. 31-603, and amendments thereto; and each cigarette listed in the certification meets the
performance standard set forth in K.S.A. 31-603, and amendments thereto.
I attest that each cigarette brand variety included in this certification has “FSC” permanently marked
in eight-point type or larger on each pack, carton, and case, or other packaging around the area of
the UPC code in accordance with K.S.A. 31-605.
I attest that, pursuant to K.S.A. 31-604(e)(i), manufacturer has appointed an agent for service of
process in Kansas and has identified the agent to the Kansas Secretary of State.
I attest that, pursuant to K.S.A. 31-605, manufacturer has provided a copy of this certification to
each licensed Kansas wholesale dealer to which manufacturer sells the cigarette brand varieties
included in this certification.
I attest that, pursuant to K.S.A. 31-604(e)(i), manufacturer consents to the jurisdiction of the Kansas
Courts for the purposes of enforcing K.S.A. 31-601 et seq.
Executed this _______ day of __________________, 20_____.
S
F
S
UBMISSION OF
IRE
TANDARDS
C
C
F
OMPLIANCE
ERTIFICATION
ORM
____________________________________
Signature of Authorized Officer or Agent
Mail this completed form and all attachments to:
Kansas State Fire Marshal
800 SW Jackson St., Ste. 104
____________________________________
Topeka, KS 66612-1216
Name (Please Print)
____________________________________
Title (Please Print)
Fire Standards Compliance Certification Form
Revised March 3, 2015
Page 5 of 5
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