CoreOne - LCP

Application for License

* Name (Name of the Business Location)

Business Physical Address

* Physical Address Line 1

Physical Address Line 2

* Physical City

* Physical State

* Physical Zipcode

* Physical County

* Phone #1

Phone #2

* Email

Business 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

Business Owner(s) Information

* Business Ownership Type

(Please explain if you answered Other)

Location ID (If registered with the Department of Revenue and reporting sales tax, on Sales and Use Tax Certificate of Registration in lower right corner.)

Business Owners

Management Role (Which best describes the Management Role of this Owner?)

Owner's Name

Ownership Role

Phone Number

Email

Date of Birth

Business Owners

Management Role (Which best describes the Management Role of this Owner?)

Owner's Name

Ownership Role

Phone Number

Email

Date of Birth

Business Owners

Management Role (Which best describes the Management Role of this Owner?)

Owner's Name

Ownership Role

Phone Number

Email

Date of Birth

Business Owners

Management Role (Which best describes the Management Role of this Owner?)

Owner's Name

Ownership Role

Phone Number

Email

Date of Birth

Business Owners

Management Role (Which best describes the Management Role of this Owner?)

Owner's Name

Ownership Role

Phone Number

Email

Date of Birth

Business Owners

Management Role (Which best describes the Management Role of this Owner?)

Owner's Name

Ownership Role

Phone Number

Email

Date of Birth

Legally Responsible Person

* Legally Responsible Person (Head decision maker, primary responsibility holder)

* Phone Number

* Email Address

Designated Contact Person

* Designated Contact Person Name

* Designated Contact Phone Number

* Designated Contact Email

Type of Business

HDC Distributor:

A person or entity that sells products containing hemp-derived cannabinoids to retailers. Also referred to as selling wholesale or third party sales.

HDC Manufacturer:

A person or entity that compounds, blends, extracts, infuses, cooks, or otherwise makes or prepares products containing a hemp-derived cannabinoid, including the processes of extraction, infusion, packaging, repackaging, labeling, and relabeling of products containing a hemp-derived cannabinoid.

HDC Re-Packager:

A person or entity that repackages batches of products containing hemp-derived cannabinoids into smaller lots to be sold to retailers or for consumption.

HDC Retailer:

A person or entity that sells products containing a hemp-derived cannabinoid for consumption and not for resale. Also referred to as direct-to-consumer sales.

Hemp Producer:

A person or entity that grows, clones, and/or propagates hemp plant(s) whether this be indoor or outdoor. Also referred to as a hemp grower or hemp farmer.

* Business Type (Referencing the descriptions of the Types of Businesses above, select all that apply.)

If you chose HDC Manufacturer, please describe your complete process.

Sales Location

Supply Location (Source of Ingredients, Materials, and/or Finished Products)

* Types of Products (Products that will be sold, processed, repackaged, and/or distributed)

* Building Size (Square footage)

Additional Business Information

Business Website (if applicable)

* Business Opening Date

* Business Days and Hours of Operation (Please provide the days and hours the business is open.)

* Name of nearest K-12 school

* Distance from that school to the location to be licensed, in feet measured as a straight line along the shortest route

* Do you have a Recall Program?

* Do you have a training program?

* Does this business conduct product testing?

Yes

No

If yes, please list the laboratory or laboratories you use for product testing.

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.

* Applicant's Name

* Applicant's 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.

Hemp-Derived Cannabinoid Application

Application for License

Business Owner(s) Information

Legally Responsible Person

Designated Contact Person

Type of Business

Additional Business Information