Medical Marijuana "Caregiver" License Application
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7Sumpter Township Police Department
MEDICAL MARIJUANA “CAREGIVER”
LICENSE APPLICATION
$2,000 – Initial License / $1,000 – Yearly Renewal Fee
(non-refundable)
All required information must be submitted at the time of application.
Attach additional pages when necessary.
APPLICANT INFORMATION
Name:
Phone:
Address:
City:
State:
Zip:
Date of Birth:
Place of Birth:
Social Security #:
Have you ever been convicted of a felony or controlled substances violation(s) in a federal,
state, or other court?
Yes
No
If yes, please provide the following:
Last Date of
Name / Location of
Date of
Incarceration /
Conviction Charge
Sentence
Court
Sentencing
Parole /
Probation
Have you ever applied as a medical marijuana “caregiver” or growing facility in another
jurisdiction?
Yes
No
If yes, state when and where:
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Parent category: Medical