Landlord Permission Form - Montana Marijuana Program
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2Montana Marijuana Program
LANDLORD PERMISSION FORM
Cardholder (patient) applicants and provider applicants must use this form to obtain permission from their landlord if
they will cultivate and/or manufacture marijuana at a property that is rented or leased.
Landlord signature must be notarized.
Fill out a new LANDLORD PERMISSION FORM if you move and you are renting or leasing the property where you
will be cultivating and manufacturing marijuana. Include this form with your CHANGE REQUEST FORM.
REGISTERED CARDHOLDER (PATIENT) OR PROVIDER/MIPP APPLICANT INFORMATION
Current card number (if current cardholder or provider):
Expiration date:
Legal Name (Last):
(First):
MI:
Date of Birth:
Social Security Number:
Location where marijuana will be cultivated and/or manufactured:
Street address
City
Zip
Signature of cardholder and/or provider
Date
LANDLORD/ PROPERTY OWNER INFORMATION
Legal Name (Last):
(First):
MI:
I give
permission to cultivate and/or manufacture marijuana at the
premises identified above to the extent that such cultivation and/or manufacturing is done in compliance with Montana
Law.
In signing this form I further attest I am the owner and/or landlord of the above named property and I have the
authority to authorize the use of the premises to cultivate and/or manufacture marijuana
Signature of landlord
Date
LANDLORD PERMISSION
1/18/2012
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