[Maryland Cannabis Administration (MCA)] Independent Laboratory Registration Renewal

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Receipt

You will be provided with a Receipt upon submission.

Independent Testing Laboratory Registration Renewal

Please make $5,000 renewal fee payable to the following address:

The Maryland Cannabis Administration

Attention-Ugo Osoh

849 International Drive, Suite 450

Linthicum, Maryland 21090

Please Provide Your Business Name(s)

Legal Name *

Trade Name (Doing Business As) *

Please provide your MCA-issued registration number

Who is the accreditation body?

What is the lab's scope of accreditation? (List all analytes the lab is certified to test)

Please upload a copy of the certificate of accreditation, the scope of accreditation, and all supporting documentation.

Click Here to Upload

Business Contact Information

IS YOUR PHYSICAL ADDRESS THE SAME AS YOUR MAILING ADDRESS?

Yes - our Physical Address is also our Mailing Address

No - our Mailing Address is different

Authorized Point-Of-Contact(s)

Primary Point-of-Contact

Name *

Title/Position *

Email *

Telephone *

Fax *

Additional Point-of-Contact (if applicable)

Name

Title/Position

Telephone

Fax

Incorporation/Formation Information

What type of business structure do you have?

Sole Proprietorship

Partnership

Limited Partnership

Limited Liability Company

C-Corporation

S-Corporation

Trust

Business Name (as it appears on formation documents)

Place of Incorporation/Formation

Date of Incorporation/Formation

Ownership Structure

Please list all persons/entities holding of record or having beneficial interest of 5% or more in the business. (For each, include: Name, Title, DOB, FEIN or SSN, Address,and Ownership %)

Has the business, a parent company, or any other intermediary business entity ever applied for a cannabis license or registration in any state or country? (regardless of whether or not the license or registration was ever issued)

Yes

Please list them and include the jurisdiction, type of license or registration, license or registration number, duration of license, and/or date of application.

Please provide any other relevant information.

Acknowledgment and Disclosure

Check "Yes" and use the blank box to acknowledge that the lab is independent from all growers, processors, and dispensaries registered with the State of Maryland.

Yes

Enter your email address here if you would like a copy of this submission.

Signature of Authorized Representative

First Name

Last Name

Choose how to sign

Draw Type

I understand and acknowledge the following: I am a representative of the Applicant who is applying to the Maryland Cannabis Administration (MCA) for an Independent Laboratory Registration. The Applicant cannot conduct business as an MCA Registrant unless the Administration finds that the Applicant meets the legal requirements for registration. During the investigation, the Administration is required to collect and evaluate various kinds of information or reports to determine if applicants meet the eligibility requirements for registration. The background investigation will include, but not be limited to, information or reports about the Applicant’s: character; general reputation; personal characteristics, including honesty and integrity; financial stability; debts to State agencies; criminal records, records of involvement with federal, state or other law enforcement agencies as specified in the application, or record of involvement with any litigation. As a representative, I have the right to request a complete and accurate disclosure of the nature and scope of the investigation and a copy of a summary of the Applicant’s rights under federal credit reporting law. I am requesting that the Administration, through its employees, agents or vendors, obtain this information about the Applicant to evaluate their eligibility for a registration. I acknowledge that this disclosure and authorization remain in effect during the time the application is pending and during the time of any Independent Laboratory Registration may be granted. By separate Authorization for Release of Information, I am authorizing any entity or individual that has information about the Applicant that I represent, to release that information to the Administration for purposes of its investigation of an applicant for a Maryland Independent Laboratory Registration.