County Of Mendocino Medical Cannabis Activity Registration Form Page 2

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Mailing Address of registrant:
____________________________________________________________________________
Telephone: ____________________ Email Address: _________________________________
Name of Property Owner:
____________________________________________________________________________
Address of Property Owner:
____________________________________________________________________________
If engaged in cultivation on or prior to January 1, 2016, please provide a description of the location, size
(dimensions or area) and nature of the medical cannabis activity and the dates during which the activity
was established and operated. Check the box below if the following applies:
 I will provide documentation (photos, Google Earth views, etc.) to verify existence of operation
as part of a cultivation application.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If this is a proposed activity, provide a description of the proposed location, size (dimensions or area)
and nature of the cannabis activity.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________ Date: ___________________________
Signature of Registrant
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