Medical Marijuana "Caregiver" License Application (Page 6 of 7) in pdf

Medical Marijuana "Caregiver" License Application Page 6

Oath of Application

I declare under penalty of perjury that this application and all attachments are true, correct,

and complete to the best of my knowledge. I also acknowledge that it is my responsibility to

comply with the provisions of Township of Sumpter Ordinance No. 107 and all rules and

regulations which govern my medical marijuana caregiver license application as well as those of

the State of Michigan.

Applicant Signature

Date

Authorization of Criminal Background Check

I hereby allow the Sumpter Township Police Department to perform a criminal background

check based on information gathered from this application form.

Applicant Signature

Date

STATE OF MICHIGAN

)

)ss.

COUNTY OF WAYNE

)

Subscribed and sworn to before a Notary Public on this ____ day of

_______________, 20____, by the above named ____________________, who has appeared

before me and presented photo identification and sworn that they have read the foregoing and

says it is true to the best of his/her knowledge.

________________________

, Notary Public

Wayne County, Michigan

My commission expires: _______________

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Medical Marijuana "Caregiver" License Application Page 6