Cultivation License Application

CULTIVATION LICENSE APPLICATION

WHEREAS, Applicant: seeks authorization to operate a commercial cultivation facility for controlled agricultural products under the regulatory authority of the issuing licensing body; and

WHEREAS, Business Name: intends to cultivate, process and store plant material at the proposed cultivation site described herein in compliance with applicable statutes, regulations, and local ordinances;

WHEREAS, Applicant submits this application, attachments and certifications to demonstrate eligibility, operational controls, security, environmental safeguards, and financial responsibility necessary for issuance of a cultivation license.

Applicant Information

Business Information

LLC   Corporation   Partnership   Sole Proprietorship   Other

Location and Premises

Total Site Area (sq ft):   Canopy Area (sq ft):

Operations — Scope of Cultivation

Indoor   Outdoor   Greenhouse

Security Plan

Alarm system installed:   24/7 monitored:

Environmental, Waste & Chemical Use

Ownership and Management

Background & Disclosures

Has any owner, officer, or managing member been convicted of a felony or a disqualifying offense related to controlled substances?   Yes   No

Fees and Payment Terms

Application Fee (non-refundable): $

Late Fee for Delinquent Payment:

Term and Termination

Requested Effective Date:    Requested Expiration Date:

Termination Notice Period (days):

Confidentiality & Records

Applicant acknowledges that information submitted in this application may be subject to public records laws. Applicant may designate specific sections as proprietary or confidential; however, designation does not guarantee exemption from disclosure. The licensing authority may disclose or retain records as required by law. Applicant further agrees to maintain records required by law and to make such records available to inspectors as authorized.

Applicant affirms that all statements in this application and any attachments are true, correct and complete. Applicant authorizes reasonable inspection of the premises, audits, and criminal background checks of listed owners and managers as part of license evaluation and ongoing compliance.

Consent to Background Check: I hereby consent to criminal background checks and verification of the information provided.

Governing Law

This application, and any license issued pursuant to it, shall be governed by the laws of the State/Locale: and any disputes shall be resolved in the appropriate courts of that jurisdiction.

Entire Agreement and Certifications

Entire Agreement: This application, together with attachments, plans, maps and any conditions of approval, constitutes the entire submission for the requested license and supersedes any prior statements or representations. No modification shall be effective unless made in writing and signed by the duly authorized representative of Applicant and the licensing authority.

Indemnification: Applicant agrees to indemnify, defend and hold harmless the licensing authority and its officers, employees and agents from and against all claims, liabilities, fines, penalties, costs and expenses (including reasonable attorneys' fees) arising out of Applicant's operations, violations of law, or breach of representations in this application, except to the extent caused by the gross negligence or willful misconduct of the licensing authority.

Applicant Certification

By signing below, Applicant certifies under penalty of perjury that the information contained in this application and all attachments is true, accurate and complete. Applicant acknowledges that knowingly making a false statement in this application may result in denial, suspension, revocation of the license and may subject Applicant to civil or criminal penalties.

Applicant further understands that the issuance of a license is conditioned upon continued compliance with applicable laws, payment of fees, successful completion of required inspections, and the licensing authority's receipt of any required municipal approvals.

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