NameFirstLast Business Name: Email Phone Business Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Type of Cannabis Business:Select valueStoreGrow/CultivationManufacturerEdibles/BakeryOther Description of operations and products you sell, produce, or manufacture What is the square footage of the building (s) occupied by the applicant at this loca Security Features:Central AlarmInterior/Exterior CamerasSecurity GuardsMotion DetectorsGated WindowsGated DoorsHold Up/Panic ButtonSafe/Vault Are there any employed professionals (e.g., physicians or pharmacists)?Select valueNoYes How much inventory is displayed to customers?Select value0-5%6-10%11-25%Greater than 25% Does applicant offer delivery of marijuana products?Select valueYesNo What is the highest concentration (%) and dosage (mg) of active cannabinoids per serving contained in the applicant’s strongest (i.e. highest dosage) product? Please provide product name, concentration (%), and dosage (mg) of active cannabinoids per serving: If the applicant distributes marijuana oils or concentrates with concentrations greater than 70% or dosages per serving greater than 50 mg, are these products only distributed to patients who have a physician recommendation for high dose product(s) or documented tolerances built up over time? Select valueYesNo If applicant distributes marijuana oils or concentrates manufactured by others, does applicant only obtain these products from manufacturers that utilize a closed-loop extraction system and non-volatile solvents in their extraction process? Select valueYesNo Does applicant grow medical or recreational marijuana or are other cannabis plants on the premises?Select valueYesNo Do any products, ingredients, or components originate from outside of the United States?Select valueYesNo For products that applicant does not produce or manufacture, does applicant obtain certificates of insurance (COIs) evidencing products coverage and AI status from all US based manufacturers or suppliers? Select valueYesNo Product Testing: Products are not contaminated with pesticidesProducts are not contaminated by bacteria☐ Products are not contaminated by mold / fungus☐ Products are not contaminated by mycotoxinsProducts are not contaminated by heavy metals☐ Products are not contaminated by residual solvents☐ Cannabinoid profiles (e.g. THCA, delta8-THC, delta9-THC, CBDA, CBD, CBG, CBN, etc.)Cannabinoid dosage per serving (milligrams per serving for each cannbinoid)Terpene profiles Financial InformationPrevious 12 months Projected next 12 months Annual gross receipts from medical marijuana (i.e. leaves, bud, flower, and trim) Annual gross receipts from infused medical marijuana edible products containing THC or other active cannabinoids (e.g. baked goods, candies, other food or drink items, tinctures, capsules, etc.) Annual gross receipts from topical medical marijuana products containing THC or other active cannabinoids (e.g. oils, creams, lotions, etc.) nnual gross receipts from medical marijuana oil cartridges or medical marijuana concentrates intended to be used with vaporizers or vapor pensAnnual gross receipts from medical marijuana concentrates not intended for use in vaporizing devices Total Medical Marijuana & Medical Marijuana Containing Products: Annual gross receipts from recreational marijuana (i.e. leaves, bud, flower, and trim) Annual gross receipts from infused recreational marijuana edible products containing THC or other active cannabinoids (e.g. baked goods, candies, other food or drink items, tinctures, capsules, etc.) nnual gross receipts from topical recreational marijuana products containing THC or other active cannabinoids (e.g. oils, creams, lotions, etc.) Annual gross receipts from recreational marijuana oil cartridges or recreational marijuana concentrates intended to be used with vaporizers or vapor pens nual gross receipts from recreational marijuana concentrates not intended for use in vaporizing devices Total Recreational Marijuana & Recreational Marijuana Containing Products:Annual gross receipts from vaporizing devices including room vaporizers and vapor pens Annual gross receipts from smoking accessory sales (e.g. pipes, rolling papers, or other non-vaporizer type smoking products) Annual gross receipts from sales of other goods (e.g. Hemp clothing, non-THC containing hemp protein, non-THC containing hemp based lotions or oils, etc.) Annual gross receipts from sales of nutritional supplementsAnnual gross receipts from services (e.g. massage, acupuncture, etc.) Total Revenues (All Products and Services): Payroll Total RevenueAnnual PayrollNumber of EmployeesCurrent Year Previous Year If applicable, name of current insurance carrier: If applicable, any claims for the past 5 years with your current insurance company?Select valueNoYes Word VerificationSubmitReset
