Maryland Medical Cannabis Commission

reporting.mmcc@maryland.gov

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

CHANGE OF MAILING ADDRESS FORM

Business Name *

MMCC License/Registration # *

Federal EIN # *

Are you a Licensee or Registrant?

Dispensary

Grower

Processor

Independent Testing Laboratory

Security Guard Agency

Secure Transport Company

Waste Disposal Company

Business Contact Information

CURRENT Mailing Address

Enter an address

Street Address Street Name

Apt, Suite, etc

City

State

Zip Code

Country

CURRENT Contact Information

Email *

Telephone *

Fax *

NEW Mailing Address

Enter an address

Street Address Street Name

Apt, Suite, etc

City

State

Zip Code

Country

NEW Contact Information

Email *

Telephone *

Fax *

IS YOUR MAILING ADDRESS THE SAME AS YOUR PHYSICAL ADDRESS?

Yes - our Mailing Address is also Physical Address

No - our Physical Address is different

Attestation of Change

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

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.