Fillable County Of Mendocino Medical Cannabis Activity Registration Form printable pdf download

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County of Mendocino

Medical Cannabis Activity Registration Form

Statement of Intent

The County of Mendocino intends to begin issuing permits for cannabis cultivation and other cannabis

activity as defined by the Medical Marijuana Regulation and Safety Act, Business and Professions Code

section 19300, et seq. (MMRSA). The purpose of this form is for the County of Mendocino to assess the

level of interest of persons to apply for local permits. Business and Professions Code section 19321(c)

provides that an existing medical cannabis facility or entity that is operating in compliance with local

requirements on or before January 1, 2018, may continue its operations until its application for a state

license for operation is acted upon. That section also provides that, in issuing licenses, the state licensing

authority shall prioritize any facility or entity that can demonstrate that it was in operation and in good

standing with the County prior to January 1, 2016.

Submission of this form will guarantee priority processing for local permit applications once they become

available and may also assist the County in making a determination that your medical cannabis facility or

entity was operating and in good standing with the County prior to January 1, 2016. However,

submitting this form does not, in any way, guarantee that you will be entitled to the issuance of

any permit or license which may now or hereafter be required by the County of

Mendocino. Submittal of the form also does not guarantee that the State of California will accept any

determination by the County of Mendocino that your facility or entity was in good standing with the

County of Mendocino for purposes of priority processing of any State license application, nor does it

guarantee issuance of any State license.

Notice

You have the right to access records containing your personal information which are maintained by the

County of Mendocino.

Civil Code section 1798.17 requires that this notice be provided when collecting

personal information from individuals. Providing the identity and other identifying information

requested on the form is voluntary. The purpose of completing and submitting this form is for the

County of Mendocino to assess the level of interest of persons to apply for local permits to engage in

any of the various types of medical cannabis activities pursuant to the Medical Marijuana Regulation

and Safety Act, Business and Professions Code section 19300, et seq. (“MMRSA”) within the County of

Mendocino. The Board of Supervisors of the County of Mendocino intends that the information that you

provide in this application shall be confidential to the greatest extent allowed by law, but you should be

aware that any information that you provide may be released as required by law, judicial order, or

subpoena, and could be used in a criminal prosecution.

Assessor’s Parcel Number of existing or proposed cannabis activity:

_____________________________________

Name of Owner or registrant:

____________________________________________________________________________

Physical Address of Location:

____________________________________________________________________________

County Of Mendocino Medical Cannabis Activity Registration Form