Application For Permit, Construction And/or Operational Approval Form Medical Cannabis Cultivation Center printable pdf download

For Department Use Only:

Illinois Department of Agriculture

Springfield, Illinois

Log No. ___________________________

APPLICATION FOR PERMIT, CONSTRUCTION AND/OR

OPERATIONAL APPROVAL

Operator: _________________________

MEDICAL CANNABIS CULTIVATION CENTER

Date Received

PERMIT Number:_____________________________

IDOA:

________________

Renewal

Modification

Facility Name __________________________________________ Telephone ____________________________

Mailing

Address____________________________________________________________________________________

Street and/or P.O Box

City, State, Zip Code

Facility

Location____________________________________________________________________________________

Street

City

State

ZIP Code

GIS

COORDINATES______________________________________________________________________________

Quarter

Section

Township

Range

P.M.

Agent-in-charge's Name/Phone No:_________________________________________________________________

Facility Owner(s) Name: _____________________________________________________________________

Preferred Mailing Address__________________________________________________________________

This Application for Permit, Construction and Operational Approval is for the purpose of applying for a cultivation

center permit or the modification of an existing permit and to verify that the proposed plans conform to the

requirements of the rules as set forth in 8 IL. Adm. Code 1000.

DESCRIPTION OF CULTIVATION CENTER OPERATION: Documents submitted as a part of this application

cover the cultivation center items checked below. If applying for a modification, you must submit the modified

schedule(s) in its entirety. Complete and attach to this application all required schedules, along with the associated

requirements for each, and all other applicable schedules and additional forms listed in the instructions as follows:

_____ Schedule 1 – Suitability of Proposed Facility

_____ Schedule 2 – Staffing and Operations Plan

_____ Schedule 3 – Security Plan

_____ Schedule 4 – Cultivation Plan

_____ Schedule 5 – Product Safety and labeling Plan

_____ Schedule 6 – Business Plan and Financial Disclosure

_____ Schedule 7 - Bonus Section

_____ Schedule 8 - Permit Modification (includes supporting documentation)

COMMENTS (If additional space is needed, please attach on a separate sheet)

IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish

the statutory purpose as outlined under the Compassionate Use of Medical Cannabis Pilot Program (410 ILCS

130) and the Department's rules adopted thereunder (8 IAC 1000). Failure to provide this information shall

prevent this form from being processed.

Application For Permit, Construction And/or Operational Approval Form Medical Cannabis Cultivation Center

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