[Maryland Cannabis Administration (MCA)] Certifying Provider Inactivation Request Form

Certifying Provider Inactivation Request Form

Please note that inactivated accounts cannot be recovered/reactivated. If you wish to re-register as a Certifying Provider in the future, you must submit a new application to MCA.

I am requesting to inactivate my status as an MCA certifying provider.

Date of Request

MCA Provider "PN" License Number: Please only enter the numerical numbers.

Last 4 digits of Social Security Number (SSN)

Date of Birth

Email (A copy of this request will be delivered to the email address provided)

Reason for Inactivation

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First Name

Last Name

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