Independent Laboratory Registration

Please make $100 registration or 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) *

This is an application for:

Registration

Renewal

Please provide your MCA-issued registration number

Is the lab 17025 ISO/IEC accredited?

Yes

Enter the labs ISO accreditation 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.

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Provisional Registration

Please submit a copy of the contract with the accreditation body applying to become accredited accompanied by a copy of the proposed scope of the accreditation.

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Please submit evidence that the independent testing laboratory has been accredited by the accreditation body in another jurisdiction.

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Please list the name, address, date of birth, and Social Security Number of each independent testing laboratory employee.

What is the accreditation timeline?

Has the lab applied for ISO accreditation?

Yes

Please upload proof of application and all supporting documentation. (e.g., confirmation email from accreditation body.)

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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

Incorporator/Founder

Please list all Incorporators and Founders of this business. (For each, include: Name, Occupation, Title, Address, Email, and Phone)

Maryland SDAT Compliance

Is this Business registered in Maryland?

Yes

Please provide your MD-SDAT registration number

Status of Good Standing

Please provide your status of Good Standing (from the Maryland Department of Assessments and Taxation - MD SDAT).

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Business History

Has the Business or any of its partners, members, managers, officers, stockholders, or directors:

Been denied a license or registration in any state?

Had a license or registration sanctioned, suspended, or revoked in any state?

Had an interest in another entity that had a privileged license or registration denied, sanctioned, suspended, or revoked in any state?

Please explain in detail, how you were denied a license or registration.

Please explain in detail, how your license or registration was sanctioned, suspended, or revoked.

Please explain in detail, how the entity you had an interest in had a privileged license or registration denied, sanctioned, suspended, or revoked.

Has a cannabis license or registration ever been issued to the Business or any of its partners, members, managers, officers, stockholders, or directors?

Yes

Please explain in detail.

Does the Business have legal control of the physical address listed above by virtue of:

Ownership

Lease

Please list the name of the landord, tenant, and date of expiration exactly as they appear on the lease.

Please upload a diagram of the physical location of the business to be registered. The diagram must label and indicate the dimensions of: limited access areas, walls, partitions, entrances, and exits. The diagram must also identify the location of any security equipment and indicate how each designated area will be utilized. (The diagram should be no larger than 8 1/2" X 11" but does not have to be to scale.)

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Excluding owners, please list all persons, firms, partnerships, corporations, limited liability companies, and trusts who will receive money/profits from this business or who will loan or give capital, inventory, gifts, services, furniture, or equipment to this business or for use by this business. (For each, include: Name, DOB, FEIN or SSN, Interest)

Please upload all notes, security instruments, written agreements, and/or details of verbal agreements by which any person, firm, partnership, corporation, limited liability company, or trust will share in the profit or gross proceeds of this business.

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Are there any agreement that are conditionally or contingently related to this business by way of volume, profit, sales, advice, or consultation?

Yes

Please upload any agreement that is conditionally or contingently related to this business by way of volume, profit, sales, advice, or consultation.

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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 %)

Other than those listed above, is there any other person, supplier, lender, landlord, etc. who will directly or indirectly receive compensation or rents based upon a percentage or share of gross proceeds or income of the registrant’s business?

Yes

Please list them.

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.

Has the business, a parent company, or any other intermediary business entity ever owned a cannabis license or registration in any state or country?

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.

Surrender: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Assurance of Voluntary Compliance: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Order to Show Cause: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Suspension: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Fine: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Revocation: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Stipulation or Settlement: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Withdrawal: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Denial of Renewal: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Other Penalty or Sanction: Please explain in detail, who received the action, in what jurisdiction, and when did the action take place.

Criminal History

Has the business, a subsidiary, or a principal employee, director, principals, officer, owner, investor, trustee, agent, or partner (of 5% or greater) ever been subject to any of the following actions in any criminal proceeding in this state or any other jurisdiction?

Yes - Indicted

Yes - Arrested

Yes - Charged

Yes - Convicted

Yes - Been a Party to

Yes - Named as an Unindicted Conspirator

Indicted: Please provide the following details; Name of the Person, Name of Case, Docket Number, Nature of Charge/Complaint, Date, Name and Address of Law Enforcement Agency, Disposition, and Sentence.

Arrested: Please provide the following details; Name of the Person, Name of Case, Docket Number, Nature of Charge/Complaint, Date, Name and Address of Law Enforcement Agency, Disposition, and Sentence.

Charged: Please provide the following details; Name of the Person, Name of Case, Docket Number, Nature of Charge/Complaint, Date, Name and Address of Law Enforcement Agency, Disposition, and Sentence.

Convicted: Please provide the following details; Name of the Person, Name of Case, Docket Number, Nature of Charge/Complaint, Date, Name and Address of Law Enforcement Agency, Disposition, and Sentence.

Been a Party to: Please provide the following details; Name of the Person, Name of Case, Docket Number, Nature of Charge/Complaint, Date, Name and Address of Law Enforcement Agency, Disposition, and Sentence.

Named as an Unindicted Conspirator: Please provide the following details; Name of the Person, Name of Case, Docket Number, Nature of Charge/Complaint, Date, Name and Address of Law Enforcement Agency, Disposition, and Sentence.

Financial History

Is the applicant, the applicant’s parent company or any other intermediary business entity delinquent in the payment of any judgments, taxes, interest, or penalties due in any jurisdiction?

Yes

Have any of the following federal/state/foreign trust or security law or regulation violations ever been filed or entered against the business, parent company, or intermediary business entity?

Yes - Complaint

Yes - Judgment

Yes - Consent Decree

Yes - Settlement

Yes - Other Disposition

Complaint: Please explain in detail.

Judgment: Please explain in detail.

Consent Decree: Please explain in detail.

Settlement: Please explain in detail.

Other Disposition: Please explain in detail.

UPLOAD REQUIRED: Please provide any documents to prove settlement of these issues. (Include any items currently under formal dispute or legal appeal.)

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In the past five (5) years, has the business, parent company, or intermediary business entity been a party to a lawsuit in this or any other state/federal/foreign jurisdiction?

Yes - Plaintiff

Yes - Defendant

Yes - Complainant

Yes - Respondent

Yes - Other Party

Plaintiff: Please explain in detail.

Defendant: Please explain in detail.

Complainant: Please explain in detail.

Respondent: Please explain in detail.

Other Party: Please explain in detail.

UPLOAD REQUIRED: Please provide any documents to prove settlement of these issues. (Include any items currently under formal dispute or legal appeal.)

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In the past two (2) years, has the business, parent company, or intermediary business entity filed a business tax return?

Yes

In the past two (2) years, has the business, parent company, or intermediary business entity completed audited or unaudited financial statements?

Yes - Audited

Yes - Unaudited

UPLOAD REQUIRED: Please provide all financial statements completed in the past two (2) years.

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UPLOAD REQUIRED: Please upload a list of the business' operating and investment accounts. (For each account, please include the name of the institution, the address, phone, and account number.)

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UPLOAD REQUIRED: Please upload a list detailing each outstanding loan and financial obligation obtained for use in this business. (For each, please include the name of the creditor, the address, phone, loan number, terms, date acquired, due date, and payment history.)

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Business Plan

Please provide a detailed plan for how the business will operate long-term. Business plan should include the following:

A description of the facility (desired square footage, number of employees to be hired, etc.);
The scope of proposed activities;
The budget and resource narratives;
A timeline for initiating operations; and
A description of the plan to ensure appropriate employee working conditions, benefits and training.

UPLOAD REQUIRED: Detailed Business Plan

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Please provide a DETAILED description of the scope of the business's proposed secure transport activities.

Please provide a DETAILED description of the business's operational budget and financial resources.

Please provide a DETAILED description of the business's timeline for initiating operations.

Please provide a DETAILED description of the business's plan to ensure appropriate employee working conditions, benefits, and training.

Please provide any other supplemental information that demonstrates this business's ability to quickly and successfully enter the market.

Please provide any other supplemental documentation that demonstrates this business's ability to quickly and successfully enter the market.

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Security Plan

The Security Plan must demonstrate that the business can assure that medical cannabis is secure at all times during transport through a detailed description of the business' standard security protocol, security protocol in the case of an emergency, how the business will employ technology and other resources to enhance security the security of its medical cannabis transportation operations, and any other relevant information.

Please provide a DETAILED description of your Standard Security Protocol.

Please provide a DETAILED description of your Security Protocol in case of emergency.

Please explain in DETAIL how your business will employ technology and other resources to enhance the security of its medical cannabis transportation operations.

Please provide any other relevant information.

Appendix A: Independent Testing Laboratory

Please provide a completed copy of Appendix A: Independent Testing Laboratory (Available for download on our website.) as well as a curriculum vitae (CV) for each employees listed in this application.

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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 Medical Cannabis Commission (“Commission”) for a Independent Laboratory Registration. The Applicant cannot conduct business as a Maryland Medical Cannabis Registrant unless the Commission finds that the Applicant meets the legal requirements for registration. During the investigation, the Commission 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 Commission, 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 Commission for purposes of its investigation of an applicant for a Maryland Independent Laboratory Registration.