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

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)

Sign Here

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.