Schedule Reg-1-Mc - Medical Cannabis Cultivation Center And Dispensing Organization Information

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Illinois Department of Revenue
Schedule REG-1-MC
Medical Cannabis Cultivation Center and
Dispensing Organization Information
Step 1: Identify your business or organization
Business name: ______________________________________________
FEIN:
______ - __________________
If your business is a corporation, are you publicly traded? ___ Yes ___ No
SSN:
_________ - ______ - ____________
(Proprietorship only)
If “Yes”, provide the ticker symbol: ________________
Phone: (______) ______ - _________
Contact for this schedule: _______________________________________
Email address: ______________________________________
Step 2: Identify your medical cannabis business activities
Note: You must have received a cultivation center permit from the Illinois Department of Agriculture or a dispensing organization registration
from the Illinois Department of Financial and Professional Regulation, prior to completing Schedule REG-1-MC.
Cultivation center - Check this box and provide the information below only if you have received a cultivation center permit from the Illinois
Department of Agriculture. (See instructions.)
Cultivation center permit number: _________________________
Cultivation center permit number: _________________________
DBA name: __________________________________________
DBA name: __________________________________________
Address: ____________________________________________
Address: ____________________________________________
Street address - No PO Box numbers
Apt. or suite no.
Street address - No PO Box numbers
Apt. or suite no.
____________________________________________
____________________________________________
City
State
ZIP
City
State
ZIP
Date cultivation center permit issued: ___ / ___ / ______
Date cultivation center permit issued: ___ / ___ / ______
Starting date of this location: ___ / ___ / ______
Starting date of this location: ___ / ___ / _______
Cultivation center permit number: _________________________
DBA name: __________________________________________
Address: ____________________________________________
Street address - No PO Box numbers
Apt. or suite no.
____________________________________________
City
State
ZIP
Date cultivation center permit issued: ___ / ___ / ______
Starting date of this location: ___ / ___ / ______
Dispensing organization - Check this box and provide the information below only if you have received a dispensing organization
registration from the Illinois Department of Financial and Professional Regulation. (See instructions.)
Dispensing organization registry ID number: ________________
Dispensing organization registry ID number: ________________
DBA name: __________________________________________
DBA name: __________________________________________
Address: ____________________________________________
Address: ____________________________________________
Street address - No PO Box numbers
Apt. or suite no.
Street address - No PO Box numbers
Apt. or suite no.
____________________________________________
____________________________________________
City
State
ZIP
City
State
ZIP
Date dispensing organization registration issued: ___ / ___ / ______
Date dispensing organization registration issued: ___ / ___ / ______
Starting date of this location: ___ / ___ / ______
Starting date of this location: ___ / ___ / ______
Dispensing organization registry ID number: ________________
Dispensing organization registry ID number: ________________
DBA name: __________________________________________
DBA name: __________________________________________
Address: ____________________________________________
Address: ____________________________________________
Street address - No PO Box numbers
Apt. or suite no.
Street address - No PO Box numbers
Apt. or suite no.
____________________________________________
____________________________________________
City
State
ZIP
City
State
ZIP
Date dispensing organization registration issued: ___ / ___ / ______
Date dispensing organization registration issued: ___ / ___ / ______
Starting date of this location: ___ / ___ / ______
Starting date of this location: ___ / ___ / ______
Dispensing organization registry ID number: ________________
DBA name: __________________________________________
Address: ____________________________________________
Street address - No PO Box numbers
Apt. or suite no.
____________________________________________
City
State
ZIP
Date dispensing organization registration issued: ___ / ___ / ______
Starting date of this location: ___ / ___ / ______
Mail your completed schedule, with
CENTRAL REGISTRATION DIVISION 3-222
ILLINOIS DEPARTMENT OF REVENUE
any required attachments to:
PO BOX 19030
SPRINGFIELD IL 62794-9030
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this
information is required. Failure to provide information may result in this form not being processed and may result in a penalty.
Schedule REG-1-MC (R-03/15)
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