Maryland Medical Cannabis Commission

enforcement.mmcc@maryland.gov

849 International Drive, 4th Floor, Linthicum, MD, 21090, US

Annual Agent Verification Reporting Form

Please select the applicable reporting period.

Are you a Licensee or Registered Ancillary Business?

Grower

Dispensary

Processor

Micro Grower

Micro Dispensary

Micro Processor

Independent Testing Laboratory

Security Guard Agency

Secure Transport Company

Waste Disposal Company

Name of Licensee or Registered Ancillary Business:

Legal Name *

Trade Name (D/B/A) (Put N/A if Not Applicable) *

MMCC License/ Registration # *

Federal EIN # *

Please upload a PDF document that contains the full legal name of each registered agent employed at any point during the reporting period. (NOTE: Each name must be listed on a separate line.)

Click Here to Upload

Was any named registered agent convicted of a felony drug offense during the reporting period?

YES. One or more of the named registered agents was convicted of a felony drug offense during the reporting period.

NO. None of the named registered agents were convicted of a felony drug offense during the reporting period.

Please explain.

Contact Email Address (confirmation email sent to this address)

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First Name

Last Name

Choose how to sign

Draw Type

I hereby confirm the following: I am a representative of the named Licensee or Registered Ancillary Business and I am authorized to submit this Report to the Maryland Medical Cannabis Commission. The information provided in this Report has been verified.