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City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
Please return completed application and
$5,000 Non-Refundable permit fee to:
Date Submitted:
City Clerk’s Office
135 East Maumee Street Application #:
Adrian, Michigan 49221
NEW RENEWAL Applications may be submitted 90 days prior to existing permit expiration.
PERMIT TYPE: Adult Use Permit Dual Purpose Permit
A $5,000 non-refundable fee applies for EACH permit type requested
MM - Medical Marihuana Permits AU - Adult Use Permits Misc. Permits
MM Class A Grower - # of: _____
MM Class B Grower - # of: _____
MM Class C Grower - # of: _____
MM Provisioning Center
AU Class A Grower - # of: _____
AU Class B Grower - # of: _____
AU Class C Grower - # of: _____
Excess Grower - # of: _____
AU Retail Establishment
Marihuana Secure Transporter
Marihuana Safety Compliance Facility
A. Renewal Applicants Only - Compliance History (New Applicants go to B.)
1. Have you ever received a citation for non-compliance of a local or state rule, regulation or law regarding your permit or
license?
Yes
No If yes please explain:
2. Has your municipal Commercial and/or adult use permit ever been suspended or revoked?
Yes
No If yes,
please explain:
3. Is your municipal Commercial and/or adult use permit currently in good standing?
Yes
No If no, please
explain:
4. If applicable, has your state Commercial and/or adult use license ever been suspended or revoked?
Yes
No
If yes, please explain:
5. If applicable, is your state Commercial and/or adult use license currently in good standing?
Yes
No If no,
please explain:
B. Commercial Marihuana Facility Business Information
Name of Company:
Federal Employer ID Number: Personal Property ID:
Business Address: Parcel Property ID:
City: State: Zip Code:
Phone: Fax: Business Website:
Business Email Contact:
Processor
Medical Marihuana Permit
Page 2 of 8
City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
C. Applicant Information
Name of Applicant: Title:
Address:
City: State: Zip Code:
Michigan ID/Driver’s License Number:
Land Line: Cell:
APPLICANT (check one):
Individual / Sole Proprietor
Partnership
LLC
Corporation Type:
D/B/A
Other/Specify:
IF A CORPORATION OR DBA, name and address of registered agent for service of process:
*If the proposed permit holder is a corporation, non-profit organization, limited liability company or any other entity
other than a natural person it must state its legal status, attach a copy of all company documents (including
amendments), proof of registration with the State of Michigan and a certificate of good standing along with the
articles, resolutions and by-laws/operating agreements.
Name:
Title:
Maiden Name or Aliases:
Home Address:
City:
State:
Zip Code:
Phone:
Business Email:
Personal Email:
Name:
Title:
Maiden Name or Aliases:
Home Address:
City:
State:
Zip Code:
Phone:
Business Email:
Personal Email:
Name:
Title:
Maiden Name or Aliases:
Home Address:
City:
State:
Zip Code:
Phone:
Business Email:
Personal Email:
Page 3 of 8
City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
Commercial Marihuana Facilities
Criminal History Disclosure and Background Record Authorization
As part of the Licensing Process, each person listed on the information submitted to the State of Michigan must also complete
this form and submit with a copy of a Michigan ID or Driver’s License. All questions on this form must be answered completely
and truthfully. A separate form for each individual listed is required.
A separate form for each individual listed on the CMF Permit application is required, including applicant, owners, partners,
corporate officers (stakeholders.)
Full Name:
Maiden Name or Aliases:
Michigan ID or Driver’s License Number:
Home Address: City: State: Zip:
Phone: Date of Birth: Gender:
I, ____________________________, affirm that I am at least 18 years of age and have not been convicted of or pled guilty or
no contest to a disqualifying felony.
I, _______________________________, authorize the release of any and all information from any appropriate agency
regarding my criminal conviction history to the City of Adrian Clerk’s Office or City of Adrian Police Department. I understand
that my race, color, sex, age, religion, national origin, height, weight, marital status, familial status, veteran status,
citizenship, handicap/disability, gender identity, sexual orientation, genetic information, or as otherwise in
accordance with all Federal or State law, or local regulations will not be made part of my application and that none of
these items will be considered in the review of my permit application. I acknowledge that a complete background
investigation, including, but not limited to, a State Police Criminal Conviction Record Check will be done. In addition, I agree
to cooperate with the investigator / inspector assigned to screening this application.
Signature: ________________________________________ Date: ___________________________
Has the applicant ever been arrested, charged, indicted or imprisoned for a felony involving controlled substances as defined under the
Michigan Public Health Code, MCL 333.11041 et seq., the federal law, or the law of any other State? Yes No
Has the applicant ever been arrested, charged, indicted or imprisoned for any other type of felony under the law of Michigan, the United
States, or any other State? Yes No
If you answered Yes to either or both of the above questions, the applicant must complete the following section.
Offense: Arrest/Charge
Indictment/Conviction
Date
Arresting
Agency
Name & Location of Court
Case
Caption
Case/Docket
Number
Disposition
Date of Conviction
Law under which the person was convicted.
SID Number
I hereby certify that the information provided above is accurate to the best of my knowledge.
Signature: ________________________________________ Date: ___________________________
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Page 4 of 8
City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
Commercial Marihuana Facilities
City Treasurer Request for Information
Each person listed on the information submitted to the State of Michigan must also complete this
form.
Applicant Information
Name:
Home Address:
City: State: Zip:
Phone: Social Security Number:
Driver’s License Number: Date of Birth:
Employer/Business Information
Corporate Name:
DBA:
Address:
City: State: Zip:
Business Phone:
Federal Employer Identification :
Do you, or any of these businesses, owe the City money for any reason? Yes No
If Yes, for what reason?
Name of any other Adrian area business in which your ownership participation exceeds 25%
Signature Date
Page 5 of 8
City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
AFFIDAVIT OF AWARENESS
ARTICLE XI COMMERCIAL MARIHUANA FACILITIES & ADULT USE ESTABLISHMENTS
I affirm that I, the applicant or operator:
Have not had a commercial license or certificate by any licensing authority in Michigan or any other
jurisdiction denied, revoked or suspended.
Has had a commercial license or certificate by any licensing authority in Michigan or any other
jurisdiction denied, revoked or suspended.
Have not had a business license denied, revoked or suspended and if revoked or suspended, list the
reason for such revocation or suspension.
I, the applicant acknowledge that I am aware of local ordinance 46-505 (c) stating any application missing
information in any required field will be deemed incomplete and is subject to denial of permit by the City
Clerk.
I, the applicant acknowledge that I am aware of local ordinance 46-502 (b) stating the issuance of any permit
or renewal permit shall not confer any vested rights, property or other right, duty, privilege or interest in a
permit of any kind or nature whatsoever including, but not limited to, any claim of entitlement or reasonable
expectation of subsequent renewal on the applicant or permit holder and shall remain valid only for one
year immediately following its approval.
I further understand that no portion of my application fee of $5,000.00 will be refunded, even if my
application is denied due to my failure to submit a “complete application”
I, the applicant, acknowledge that I am aware and understand that all matters related to Marihuana, growing,
cultivation, possession, dispensing, testing, safety compliance, transporting, distribution, and use are
currently subject to state laws, rules and regulations, and that the approval or granting of a permit
hereunder does not exonerate or exculpate the applicant from abiding by the provisions and requirements
and penalties associated with those laws, rules and regulations or exposure to any penalties associated
therewith; and further waive and forever release any claim demand, action, legal redress or recourse
against the City of Adrian, its elected and appointed officials and its employees and agents for claims,
damages, liabilities, causes of action, and attorney fees that applicant may incur as a result of violation by
applicant, its officials, members, partners, shareholders, employees and agents, of those laws, rules and
regulations and hereby waive and assume the risk of any such claims and damages and lack of recourse
against the City of Adrian, its elected and appointed officials, employees, attorneys and agents.
I, the applicant affirm that neither I nor any stakeholder is in default to the City of Adrian, specifically, that
I, the applicant, have not failed to pay any property taxes, special assessments, fines, fees or other financial
obligation to the City.
I, the applicant acknowledge that I am aware of the local ordinance requirement that cultivation be
performed in an enclosed building.
Signature of Applicant Signature of Co-Applicant
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Page 6 of 8
City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
NOTARIZED APPLICANT CHECKLIST
Every applicant for a Marihuana facility, establishment, or other business permit shall complete and file the
application form provided by the city clerk's office. Any application missing information in any required field will be
deemed incomplete and is subject to denial of the permit by the city clerk. Each question in the application must be
answered in its entirety and all the information requested and required by this article must be submitted with the
application. Failure to comply with these rules and the application requirements in this article is grounds for denial
of the application. An application for a Commercial Marihuana Facility Permit shall contain any information required
by the Medical Marihuana Facilities Licensing Act, MCL 333.27101 et seq. and/or the Michigan Regulation and Taxation
of Marihuana Act, MCL 333.27951 et seq., and shall also contain all of the following:
All documentation showing approved pre-qualification status or the required valid State Marihuana License.
If the proposed permit holder is an individual, the applicant’s name, date of birth, physical address, email, one or
more phone numbers, including emergency contact information, and a copy of a valid unexpired driver’s license or
State ID.
If the applicant is not an individual, the names, dates of birth, physical addresses, email addresses, and one or more
phone numbers of each stakeholder of the applicant, including designation of a stake holder as an emergency
contact person and contact information for the emergency contact person, a copy of a valid unexpired driver’s
license or State ID for each proposed permit holder.
Articles of incorporation of organization, internal revenue service SS-4 EIN confirmation letter, and the operating
agreement or bylaws of the applicant, if a limited liability company are required.
The name and address of the proposed Commercial Marihuana establishment and any additional contact
information including name, address, and telephone number of the owner(s) of all real property where the facility is
located.
Proof of ownership of the entire premises wherein the Commercial Marihuana establishment is to be operated; or
written consent from the property owner for use of the premises with a copy of any lease for the premises.
A signed release permitting the city police department to perform a criminal background check.
A signed acknowledgement that the applicant is aware and understands that all matters related to marihuana,
growing, cultivation, possession, dispensing, testing, safety compliance, transporting, distribution, and use are
currently subject to state laws, rules and regulations, and that the approval or granting of a permit hereunder does
not exonerate or exculpate the applicant from abiding by the provisions and requirements and penalties associated
with those laws, rules and regulations or exposure to any penalties associated therewith; and further the applicant
waives and forever releases any claim demand, action, legal redress or recourse against the City, its elected and
appointed officials and its employees and agents for any claims, damages, liabilities, causes of action, and attorney
fees that applicant may incur as a result of a violation by applicant, its officials, members, partners, shareholders,
employees and agents, of those laws, rules and regulations and hereby waives and assumes the risk of any such
claims and damages and lack of recourse against the City, its elected and appointed officials, employees, attorneys,
and agents.
A signed acknowledgement that all cultivation must be performed in an enclosed building.
An affidavit that the applicant nor any stakeholder of the applicant is not in default to the city. Specifically, that the
applicant or stakeholder of the applicant has not failed to pay any property taxes, special assessments, fines, fees
or other financial obligation to the city.
Proof of a surety bond for each permit type, in the amount of $100,000.00 with the City listed as the obligee to
guarantee the performance by applicant of the terms, conditions and obligations of this article or in the alternative
applicant can create an escrow account for the benefit of the city at a city-approved financial institution in the amount
of $20,000.00.
Proof of an insurance policy covering each facility and naming the City, its elected and appointed officials,
employees, and agents, as additional insured parties, available for the payment of any damages arising out of an
act or omission of the applicant or its stakeholders, agents, employees, or subcontractors, in the amount of (a) at
least $1,000,000.00 for property damage: (b) at least $1,000,000.00 for injury to one person; and (c) at least
$2,000,000.00 for injury to two or more persons resulting from the same occurrence. The insurance policy
underwriter must have a minimum A.M. Best Company insurance ranking of B+, consistent with State law.
If applicable, a copy of the social equity plan submitted to the State.
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City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
NOTARIZED APPLICANT CHECKLIST
Any other information deemed by the City to be required for consideration of a permit.
Please specify:
I,________________________(applicant) intend to acquire and maintain a valid Marihuana Facility License from the State
of Michigan and maintain a Marihuana Facility Permit. I understand and agree that in the event of a lapse in my state issued
Commercial Marihuana Facility License, for any reason, I may not continue operation of any Marihuana Facility in the City
of Adrian, unless and until a valid state license is reinstated or obtained.
_____________________________________________________ ___________________________
Signature Date
NOTARY SECTION
I, ______________________________________ acknowledge that the attached application is complete and in
accordance with Article XI. Commercial Marihuana Facilities Ordinance, Sec.46-505, and that all statements contained
herein are truthful to the best of my knowledge.
Acknowledged before me in _____________ County, Michigan, on _____________________________ (the date), by
______________________ (name of signatory).
____________________________________
Notary Public Signature
Print Name _________________________
My commission expires: _______________
Acting in the County of ________________
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Page 8 of 8
City of Adrian
Commercial Marihuana Facilities Permit
APPLICATION
AFFIDAVIT:
I (we) the undersigned affirm that the foregoing answers, statements, and information, and any attachments, are in all
respects true and correct to the best of my (our) knowledge and belief. I the undersigned understand that this application
is for approval to operate a Commercial Marihuana facility or facilities within the City of Adrian and that approved City
application may be used as part of an application to the State of Michigan for a Commercial Marihuana Facility or
Facilities to be operated within the City.
I, the undersigned, understand that if I am authorized by the City of Adrian but my application to the State of Michigan
for a state operating license is denied, that the City Clerk will cancel any prior authorization and I will forfeit the initial
application fee.
I understand that I do not have the right to a particular location or zoning district by making this application. I understand
that I will be required to submit a separate zoning application, together with an application fee and escrow amount, to be
utilized by the City in processing my zoning application; which is separate from the initial application fee that I have paid
to the City as part of this application.
I will not operate a Commercial Marihuana facility or facilities within the City unless and until I have received approval
for the location and site plan approval as required by the City Zoning Ordinance, and a state license for the facility or
facilities.
I agree to report any changes to the information in this application to the City Clerk within ten (10) business days.
SUBMITTAL INSTRUCTIONS AND FEES
This application must be returned with a payment for the $5,000 non-refundable application fee to the following
address:
Robin Connor, Clerk
City of Adrian
135 East Maumee Street
Adrian, Michigan 49221
Telephone: 517-264-4866 Fax: 517-264-8016
The check for the application fee shall be made out to the City of Adrian.
The Applicant is responsible for being sufficiently familiar with and having
working knowledge of the ordinance requirements.
A copy of Article XI Commercial Marihuana Facilities,
is available on the City of Adrian’s
website www.adriancity.com.
Applicant’s Signature(s) Date Co-Applicant’s Signature(s) Date
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