Application For Permit, Construction And/or Operational Approval Form Medical Cannabis Cultivation Center (Page 2 of 2) in pdf

Application For Permit, Construction And/or Operational Approval Form Medical Cannabis Cultivation Center Page 2

APPROVALS OF APPLICATION FOR PERMIT

1. Certification of Engineering Plans and Specifications:

a) Certificate by Applicant or Employee of Applicant (Must be completed)

I hereby certify that I am familiar with the information contained in this application, the attached

schedules, and that to the best of my knowledge and belief such information is true, complete,

and accurate, and the engineering plans and specifications were prepared by me or under my

direction.

Name_______________________________________ Title______________________________

Signature____________________________________ Date______________________________

b) Certificate by Design Engineer

I hereby certify that I am familiar with the contents of this application and the rules for The

Compassionate Use of Medical Cannabis Pilot Program, that the design of the cultivation

center conforms to the requirements of the rules, and the engineering plans and specifications

were prepared by me or under my direction.

Engineer ______________________________________________________________________

Name

Registration No.

Seal

Firm __________________________________________________________________________

Address: _______________________________________ Telephone No. _____________________

Signature ______________________________________ Date _______________________________

2. Certification of Application for Medical Cannabis Cultivation Center :

Certificate by Applicant(s)

I/We hereby certify that I/We are familiar with the contents of this application, the attached

schedules, and am/are authorized to sign this application in accordance with 8 IAC 1000.100(e) of

the rules. I/We agree and understand that conditions of License Approval are that I/we construct

and operate the Medicinal Marijuana Cultivation Center as submitted in this application and

conform to all requirements of Part 1000.

Authorized Applicant:

Name_________________________________ Title _______________________________________

Signature ______________________________________________ Date _______________________

Company Name ___________________________________________________________________

Application For Permit, Construction And/or Operational Approval Form Medical Cannabis Cultivation Center Page 2