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3. License for

   1. Renewal
   2. Change of Ownership
   3. Modification to Premises
4. License Fee: $1,000
5. License Type

   1. Medical Marijuana Center
   2. Medical Marijuana Infused Products
   3. Medical Marijuana Optional Premises Cultivation
7. Applicant’s Legal Business Name / Trade Name (DBA)
9. 12 Digit Parcel ID Number
10. Zone District
11. Business Phone Number
13. Physical Address
15. Mailing Address
17. City
18. State
19. Zip
21. Primary Contact Person
23. Primary Contact Person for Business
24. Primary Contact Email Address
26. Primary Contact Phone Number
27. Primary Contact Cell Number
29. Primary Contact Address
31. Address2
33. City
34. State
35. Zip
37. State Medical Marijuana License Numbers
39. Medical Marijuana Center Number
40. Optional Premises Cultivation Number
41. Infused Products Number
43. Applicant’s Signature
44. Date
    Date
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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field