Form Center

2. Facility - Business Information
4. Legal Business Name*
5. Federal Employer Identification Number (FEIN)*
7. Company Name (DBA)
8. State Cultivation License Number*
10. Address of Facility*
11. Cultivation License Holder Name*
13. City*
14. State*
15. Culitvation LIcense Holder Phone*
17. Zip Code*
19. Cultivation License Holder Email*
21. Business Owner Contact Name*
23. Business Owner Contact Phone*
24. Business Owner contact Email*
26. Business Contact Name*
28. Business Contact Phone*
29. Business Contact Email*
33. Accountant Information
35. Does Your Company use an Outside Accountant?*

    1. Yes

    1. No
37. Accounting Firm Name
38. Accounting Firm Phone Number
40. Accountant Contact Name
41. Accounting Firm Email
43. Accounting Firm Address
45. City
46. State
47. Zip Code
49. Does Your Company have an Internal Accountant?*

    1. Yes

    1. No
51. Internal Accountant Name
52. Internal Accountant Phone Number
54. Internal Accountant Principal Address
55. Internal Accountant Email
57. City
58. State
59. Zip Code
63. Authorized Signature*
65. Title*
67. Date*
69. By checking this box I verify that I am an Authorized to sign legal documents for this Business*

    1. Yes
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field