MEDICAL FACILITY REGISTRATION

Medical Facility Name

OHCQ License #

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

Telephone

Fax

What type of medical facility are you?

Telephone

Fax

Email Address

Telephone

Fax

Email Address

Telephone

Fax

Email Address

Telephone

Fax

Email Address

Telephone

Fax

Email Address

Telephone

Fax

Email Address

Operating Plan

How will the facility verify that the qualifying patient or their qualifying caregiver is registered to consume medical cannabis?

What are the facility's safety protocols for receiving, storing, and administering medical cannabis?

How will the facility track how/when/why medical cannabis is received and administered?

How will the facility prevent diversion of medical cannabis?

Acknowledgment and Disclosure

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 Maryland Medical Cannabis Business 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 licensure. 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 Maryland Medical Cannabis Business Registration that 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 Medical Cannabis Business Registration.