11-12-2014 Council Agenda - Laserfiche WebLink

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Retailer Information Enter Retailer information below. If "Individual' is selected, provide Individual First Name and Individual Last Name. If "Entity" is selected, provide Entity Full Name. Individual Entity (e.g., corporation, partnership, or limited liability company) Individual First Name: (only If "Individual" selected) Individual Last Name: (only if "Individual" selected) Entity Full Name: (only if "Entity" selected) Street Address: City, State, Zip: Telephone Number: Retailer's Officers, Directors, and Senior Managers. Please list each of Retailer's officers, directors, and senior managers. If Entity is selected in Retailer Information above, list Retailers chief executive officer first. First Name: Last Name: Title: First Name: Last Name: Title: First Name: Last Name: Title: First Name: Last Name: Title: First Name: Last Name: Title: Electronic Notice, Electronic Transactions, and the Website PM USA, IN ITS SOLE DISCRETION, MAY PROVIDE SOME OR ALL NOTICES AND OFFERS RELATED TO THE PROGRAM OR PM USA PROMOTIONS ELECTRONICALLY THROUGH THE WEBSITE. RETAILER AGREES TO CONDUCT TRANSACTIONS, IF APPLICABLE, AND TO RECEIVE NOTICES AND OFFERS RELATED TO THE PROGRAM OR PM USA PROMOTIONS ELECTRONICALLY THROUGH THE WEBSITE. Marlboro Product Promotions Acceptance Election. If Retailer participates in the Program at the Premium Level, then Retailer must participate in Marlboro Product Promotion Acceptance, set forth in Exhibit C. By selecting "No" below, Retailer acknowledges that it will not earn a Merchandising Payment each Quarter. If Retailer participates in the Program at the Choice Level, then Retailer may elect to participate in Marlboro Product Promotion Acceptance, set forth in Exhibit C. Selecting "No" has no effect on Retailer's Merchandising Payment. 8 Yes, Retailer will participate in Marlboro Product Promotion Acceptance. [, No. Retailer will not participate in Marlboro Product Promotion Acceptance. Page 2 of 4 18