CoreOne - LCP

* Name (Business/Farm Name. License will be issued to the NAME/BUSINESS listed )

* License being applied for (check the one that constitutes the majority of your business)

* Owner's Name (Legally responsible person/Key Participant)

* Owner's Phone

* Owner's Email

Business EIN

* DOB (Individual or partner in general partnership)

Website

* Contact Person (Primary Contact Name )

* Phone #1 (Primary Contact Phone)

* Email (Primary Contact Email)

Physical Address (Growing)

* Physical Address Line 1

Physical Address Line 2

* Physical City

* Physical State

* Physical Zipcode

* Physical County (for example "Davidson" )

Mailing Address

* Is the Mailing Address the same as Physical Address? (If "No", please provide the Mailing Address)

Mailing Address Line 1

Mailing Address Line 2

Mailing City

Mailing State

Mailing Zipcode

Mailing County (for example "Davidson")

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT. I FULLY UNDERSTAND THAT ANY DEVIATION FROM THE ABOVE WITHOUT PRIOR PERMISSION FROM THIS STATE REGULATORY AGENCY MAY NULLIFY FINAL APPROVAL. I FURTHER UNDERSTAND THAT ANY MATERIAL FALSIFICATION OF ANY INFORMATION IN THIS APPLICATION SHALL DEEM ME INELIGIBLE TO PARTICIPATE IN THE PROGRAM.

* I confirm I have read and understand the Application Instructions.

* Company Representative

* Company Representative Signature

* Date

ACCEPTANCE OF THIS APPLICATION BY THIS REGULATORY AUTHORITY DOES NOT INDICATE FINAL APPROVAL FOR LICENSING. ADDITIONALLY, ACCEPTANCE OF THIS APPLICATION BY THIS REGULATORY AUTHORITY DOES NOT INDICATE COMPLIANCE WITH ANY OTHER CODE, LAW, OR REGULATION THAT MAY BE REQUIRED – FEDERAL, STATE, OR LOCAL.

If "Please Wait" does not replace the submit button and no confirmation appears after clicking "Submit," please review the questions above and answer any required ones marked in red.

Tennessee Department of Agriculture

Consumer and Industry Services

New Hemp Producer Application