Organization, Ownership, and Control Disclosure

Effective May 18, 2020 COMAR 10.62.08.12, 10.62.19.10, and 10.62.25.11 require each licensee to submit information regarding ownership and control by July 1 each year. Failure to submit this report may result in a fine, suspension/revocation, or both.

Please direct any questions regarding this report to reporting.mmcc@maryland.gov.

Please indicate the reason for submission:

Licensee Information

License Type

Grower

Processor

Dispensary

Licensee Name

Legal Name *

Trade Name (If none, enter N/A) *

License Number

Corporate Structure

Please upload a chart or table demonstrating the corporate structure of the licensee. The chart or table must identify:

The names of any parent, holding, affiliate, or subsidiary companies; and
The relationship between the parent, holding, affiliate, or subsidiary companies and the licensee.

Important: this includes any third-party "management company" that operates the licensee's business. The licensee must upload a chart or table demonstrating the relationship between the management company and any parent, holding, affiliate, or subsidiary of the management company.

If NONE, upload a signed attestation that the licensee has no parent, holding, affiliate, or subsidiary companies and no management company.

Upload Corporate Structure Chart/Table or Signed Attestation

Click Here to Upload

Organizational Chart

Please provide a hierarchical organizational chart of the licensee, which identifies the name and office/title of any of the below members of the organization:

Members of the Board of Directors;
Principal and/or corporate officers (e.g. Chief Executive Officer, Chief Operating Officer, Senior Vice President, etc.); and
Members of management (including anyone who has a role in the day-to-day management of the licensee).

Upload Organizational Chart

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Capitalization Table

Please complete and submit a capitalization table using the Excel template provided on our website

Click Here to Upload

Attestation

I attest that the information reported on this form is accurate and complete as of this date: (Click on the box to select a date from the calendar)

Contact Email Address (confirmation email sent to this address)

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First Name

Last Name

Choose how to sign

Draw Type

I hereby confirm the following: I am a representative of the named Licensee and I am authorized to submit this Request to Organization, Ownership, and Control Disclosure Report to the Maryland Medical Cannabis Commission. The information provided in this report has been verified.