Fillable ADULT USE MARIJUANA PROGRAM FEE WAIVER A T (Arizona Department of Health Services)

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ADULT USE MARIJUANA PROGRAM FEE WAIVER A T (Arizona Department of Health Services)

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Revised 05.11.2021
ADULT USE MARIJUANA PROGRAM
FEE WAIVER A T TE S T A T I O N
FOR FACILITY AGENT APPLICATION
I,____________________________________________________, attest under penalty of perjury that:
(Please print full legal name)
• I meet the following fee waiver eligibility requirements, as specified in A.R.S. §41-1080.01:
I am applying for a marijuana facility agent license for the first time in Arizona
AND
My family income does not exceed 200% of the federal poverty guidelines.
Signature of Facility Agent Applicant Date Signed
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ADULT USE MARIJUANA PROGRAM FEE WAIVER A T (Arizona Department of Health Services)

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Completed 11 May 2022

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