Medical Marijuana "Caregiver" License Application Page 2

Have you ever been denied an application as a medical marijuana “caregiver” facility from any

jurisdiction?

Yes

If yes state when, where and why:

Have you ever had a medical marijuana “caregiver” facility license suspended or revoked by any

jurisdiction?

Yes

If yes state when, where and why:

PROPERTY OWNER INFORMATION

Owner Name:

Home Address:

Home Phone:

City:

State:

Zip:

Do you have legal possession of the premises by virtue of ownership, lease or other arrangement?

Ownership

Lease

Other (explain in detail)

Attach proof of ownership or copy of lease.

If premises are leased, attach a notarized letter giving permission from the owner of the premises

for it’s use as a medical marijuana “caregiver” faclilty.

PROPERTY INFORMATION

Does the property / facility have an alarm system in place?

Yes

If yes, give name of alarm company, contact name and telephone number:

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Parent category: Medical