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Agent Application (State of Nevada, Department of Information Technology)

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1
10/18/2017
Marijuana Establishment Agent Card
Application and Checklist
State of Nevada Department of Taxation
For use by Marijuana Establishment Owners, Officers, Board Members,
Employees, Volunteers and Contractors
2
10/18/2017
Marijuana Agent Card Application Packet Checklist
Please follow this checklist carefully when submitting your application or renewal. All fees collected by the
Nevada Marijuana Enforcement Division for agent registration cards are non-refundable. All required agent
registration or renewal application forms must be filled out completely. Incomplete or illegible application/
renewal packets will be returned, delaying the acceptance process.
Agent Basic Information Document
Applicant Required Attestation Form
Applicant Dispense/Divert Pledge Form
Passport
photo for registration card
Scanned signature for registration card
____ Set of fingerprints for background investigation submitted through a local fingerprinting office.
____ Agent Applicant Fingerprint Submission Form: Submit this form with your packet to
Department of Taxation. Do not submit it to Department of Public Safety.
Fingerprint Background
Waiver. Submit this form with your packet to Department of Taxation.
Do not submit it to Department of Public Safety.
Photocopy
of government issued ID: You must provide a copy of your government issued
driver’s license or identification card.
Registration fee: Payment to the Department of Taxation in the amount of $75.00. All payments must
be in the form of check or money order. Do not write the word “marijuana” on your check or money
order.
NOTE: Applicant
s are hereby notified that both state and FBI background checks are required. If only one of
these is available, the Department may notify applicants and direct them to submit another set of fingerprints
at a later date to meet this requirement.
Submit through the Department of Taxation's online portal.
Department of Taxation
Attn: Agent Registration
1550 College Parkway Suite 115
Carson City, Nevada 89706
Submission Options:
Submit in person at any Department of Taxation office.
Mail completed forms and fee payment to:
Forms submitted in person must contain original signatures. Acceptance notification will either be provided
in person, emailed or mailed to the address provided by the applicant. A complete application includes:
Nevada Marijuana Enforcement Division
3
10/18/2017
Nevada Marijuana Agent Card Facts
Agents must be at least 21 years of age.
Agents must not have a criminal record containing excluded felony conviction(s).
Applicants must not have had a previous agent registration card revoked.
Agent registration cards cannot be approved if the applicant is subject to a court order for support of a child and is
not in compliance with the court order.
Denials or revocations of agent registration cards will include a notification to the applicant of the specific reasons
for the
action.
With the exception of contractor agents, a person to whom an agent registration card is issued may only be
employed by
or volunteer at the type of
establishment for which he or she is registered. Contractors may
contract with any registered Nevada marijuana establishment.
Establishments must provide agents with training before they begin to work or volunteer. Training topics for all
establishment types include security m
easures, emergency procedures and confidentiality. Further, each
establishment type has specific training
topics that must be covered.
Issuance of a Nevada marijuana agent registration card does not exempt the holder from prosecution under federal
law. NRS 453A and NRS 453D provide exemption from prosecution under state laws. It is recommended you
discuss the limitations and liabilities that are
associated with existing federal laws with your personal attorney.
An agent registration card is valid for one year from the date of issue. Renewals must be submitted at least 30 days
in advance of the expiration
date to avoid expiration and possible lapse in employment. If your card is lost, please contact
the Marijuana
Enforcement Division
immediately at marijuana@tax.state.nv.us and put “Lost Card” in the subject line.
Renewals involve the same process as applying for the first time; the cost is $75.00.
Nevada marijuana agent registration cards are not transferrable.
Name and/or address changes for an agent registration card must be submitted to the Department.
To replace a lost, stolen or destroyed card, contact the Department within 3 working days of the loss.
The Department may, by regulation, require additional information.
The Department will temporarily register marijuana agents upon receipt of a complete application, which includes
payment of required agent registration fees.
Nevada Marijuana Enforcement Division
NEW
Applicant
Nevada Marijuana Enforcement Division
Agent Basic Information Document
The information on this form is required for all agent registration applications. Enter the required
information below, print and sign where required.
Please type or print le
gibly.
NAME (FIRST MIDDLE LAST)
DATE OF BIRTH
PHYSICAL ADDRESS1 (
ADDRESS ON GOVERNMENT ID
)
MOBILE PHONE NUMBER
PHYSICAL ADDRESS2
HOME PHONE NUMBER
PHYSICAL CITY, STATE ZIPCODE (TOWN, CITY, PROVINCE, POSTAL CODE)
SOCIAL SECURITY NUMBER (optional)
MAILING ADDRESS1 (
IF DIFFERENT FROM ABOVE
)
APPLICANT ROLE (CHECK ALL THAT APPLY)
☐
EMPLOYEE ☐CONTRACTOR
☐
VOLUNTEER ☐OWNER/OFFICER/BOARD MEMBER
MAILING ADDRESS2
IF OWNER/OFFICER/BOARD MEMBER (CHECK ALL
THAT APPLY
)
☐OWNER ☐OFFICER ☐BOARD MEMBER
MAILING CITY, STATE ZIPCODE (TOWN, CITY, PROVINCE, POSTAL CODE)
IF OWNER/OFFICER/BOARD MEMBER, LIST 4-DIGIT
ME
CODE:
EMAIL
IF CONTRACTOR OR DISTRIBUTOR, LIST PARENT
COMPANY:
DATE OF APPLICATION
Identification
Other Information
Establishment Category: You may apply for more than one category of agent card, but must include
$75 for each category you are applying for. Check the categories you wish to apply for.
☐Cultivation ☐Production ☐Dispensary ☐Laboratory ☐Distributor
GOVERNMENT ID NUMBER
GENDER
4
SIGNATURE
Name
Nevada Marijuana Enforcement Division
Driver’s License Front
NAME
PHYSICAL ADDRESS
PHYSICAL CITY, STATE ZIPCODE
Copy the front of driver’s license (or state/federal issued photo identification) into the area below.
If photocopying, insert this sheet into the photocopy machine.
5
Name
Nevada Marijuana Enforcement Division
Driver’s License Back
NAME
PHYSICAL ADDRESS
PHYSICAL CITY, STATE ZIPCODE
Copy the back of driver’s license (or state/federal issued photo identification) into the area
below. If photocopying, insert this sheet into the photocopy machine.
6
Applicant Required Attestation Form
All agent applicants must attest to the following:
1. They have not been convicted of an excluded offense. An excluded offense is a
crime of violence or a violation of a state or federal law pertaining to controlled
substances if the law was punishable as a felony in the jurisdiction where the
person was convicted.
2.
They do not currently have an establishment agent registration card, or if they do, they must
supply
the card number of the current card.
3.
They have not had a marijuana establishment agent card revoked.
4.
They are in compliance with any court order for the support of a child
.
Name of Applicant: ______________________ DOB: ____________ SSN(optional): _____________
Mailing Address of Applicant: _________________________________________________
City: ________________________ State: _________________ Zip: _________________
Applicant Attestations
1. I, , attest that I have not been convicted of an excluded felony offense.
2.
I, , attest that I do not currently have an establishment agent registration
card OR I do and this is the registration number: ___________________.
3.
I, , attest that I have not had a marijuana establishment agent
registration card revoked.
4. I, , attest that I am in compliance with my court order for
support of a child OR I am not under any court orders.
Signature of Applicant: __________________________ Date: _________________
________________
________________
________________
________________
7
Nevada Marijuana Enforcement Division
Print, sign and submit this form with your agent card application packet.
Applicant Dispense/Divert Pledge Form
All new agent registration and renewal applications for establishment agent registration
cards must pledge to the following:
1. Not to dispense or divert marijuana or marijuana products to unauthorized persons.
Print, sign and submit this form with your agent card application packet.
Name of Applicant: ____________________ DOB: _____________ SSN (optional): ___________
Mailing Address of Applicant: ___________________________________________________
City: ______________________________ State: ___________ Zip: ________________
I, , pledge not to dispense or otherwise divert marijuana to
any person who is not authorized to possess marijuana in accordance with provisions of
Nevada Revised Statute 453A and/or NRS 453D.
Signature of Applicant: ________________________ Date: ________________________
____________________
8
Nevada Marijuana Enforcement Division
Agent Photograph and Signature
Affix agent photograph and sign in the appropriate boxes below.
Photograph
The applicant will need to obtain a standard
United States passport photograph that is 2
inches in both height and width. These can
be obtained at many United State Post
Offices as well as private establishments
(Walgreens, etc.). Glue (or affix in some
manner other than tape) the photograph
inside of the marks to the right.
Signature
Applicant signature needs to be entered into
the box to the right. The box is defined by
the horizontal and vertical marks. This
allows the signature to be scanned without
a black border. The box is 1 inch high and 3
inches in length. Sign using a black pen.
9
Nevada Marijuana Enforcement Division
As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based
criminal history record check for a noncriminal justice purpose you have certain rights which are
discussed below.
1. You must be notified by (enter name of requesting agency) State of Nevada Department of Taxation
that your fingerprints will be used to check the criminal history records of the FBI and State of Nevada.
2. If you have
a criminal history record the officials making a determination of your suitability for the job,
license or other benefit for which you are applying must provide you the opportunity to complete or
challenge the accuracy of the information in the record. You may review and challenge the accuracy of
any and all criminal history records which are returned to the submitting agency. The proper forms and
procedures will be furnished to you by the Nevada Department of Public Safety, Records Bureau upon
request. If you decide to challenge the accuracy or completeness of you FBI criminal history record,
Title 28 of the Code of Federal Regulations Section 16.34 provides for the proper procedure to do so:
16.34 – Procedure to obtain change, correction or updating of identification records.
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or
incomplete in any respect and wishes changes, corrections or updating of the alleged deficiency, he/she
should make application directly to the agency which contributed the questioned information. The
subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on
his/her record to the FBI, Criminal Justice Information Services (CJIS) Division ATTN: SCU, Mod. D-
2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the
agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon
the receipt of an official communication directly from the agency which contributed the original
information, the FBI CJIS Division will make any changes necessary in accordance with the
information supplied by that agency.
3. Based on 28 CF
R § 50.12 (b), officials making such determinations should not deny the license or
employment based on information in the record until the applicant has been afforded a reasonable time
to correct or complete the record or has declined to do so.
4. You have
the right to expect that officials receiving the results of the fingerprint-based criminal history
record check will use it for only authorized purposes and will not retain or disseminate it in violation of
federal or state statute, regulation or executive order, or rule, procedure or standard established by the
National Crime Prevention and Privacy Compact Council.
5. I hereby authorize (enter name of requesting agency) State of Nevada Department of Taxation to
submit a set of fingerprints to the Nevada Department of Public Safety, Records Bureau for the purpose
of accessing and reviewing State of Nevada and FBI criminal history records that may pertain to me.
In giving this authorization, I expressly understand that the records may include information pertaining
to notations of arrest, detainments, indictments, information for other charges for which the final court
disposition is pending or is unknown to the above referred agency. For records containing final court
disposition information, I understand that the release may include information pertaining to dismissals,
acquittals, convictions, sentences, correctional supervision information and information concerning the
status of my parole or probation when applicable.
10
6. I hereby release from liability and promise to hold harmless under any and all causes of legal action,
the State of Nevada, its officer(s), agent(s) and /or employee(s) who conducted my criminal history
records search and provided information to the submitting agency for any statement(s), omission(s), or
infringement(s) upon my current legal rights. I further release and promise to hold harmless and
covenant not to sue any persons, firms, institutions or agencies providing such information to the State
of Nevada on the basis of their disclosures. I have signed this release voluntarily and of my own free
will.
A reproduction
of this authorization for release of information by photocopy, facsimile or similar
process, shall for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature
voluntarily appears below; do hereby and irrevocably agree to the above.
Applicant's Name: _
_
(PRINT: Last, First, Middle)
Address: _____________________________________________________
Applicant’s Signature: ___________________________________________
Date: ________________________________________________________
11
Agent Fingerprint Submission Instructions
1. Complete/print a Marijuana Agent Fingerprint Submission Form to bring to your fingerprinting site. The
fingerprint technician will stamp, sign, date and annotate the Transaction Control Number (TCN#), if
applicable, in the lower right corner of the form and return it to you.
2. State-specific data for the fingerprint card:
ORI: NV0131700
MNU: 152108
Reason Fingerprinted:
Your role in a MEDICAL marijuana establishment Reason Fingerprinted
Current owner, officer or board member NRS 453A.322
Employee, volunteer or contractor NRS 453A.332
Prospective owner, officer or board member NRS 453A.334
Your role in a RECREATIONAL marijuana establishment Reason Fingerprinted
Current owner, officer or board member NRS 453D
Employee, volunteer or contractor NRS 453D
Prospective owner, officer or board member NRS 453D
3. NOTE: If you work, or will work for a “dual licensee” establishment (a facility that is registered and
licensed to operate as both a medical and recreational marijuana establishment), you are required to submit
two sets of fingerprints. The fingerprints for a medical establishment must cite the appropriate NRS 453A
above, and the recreational fingerprints must cite NRS 453D as the Reason Fingerprinted.
4. LiveScan (electronic) submission of fingerprints is REQUIRED for all applicants who will be fingerprinted
in Nevada. Instructions for applicants who will be fingerprinted in another state appear in number 6 below.
5. Select a fingerprinting site (Nevada). Fee information and lists of law enforcement and private
fingerprinting sites are posted on the DPS Website: http://rccd.nv.gov/FeesForms/Fingerprints/
6. Fingerprinting in states other than Nevada: Obtain physical fingerprint cards (form FD-258) from an
authorized fingerprinting site in your state. Complete all required information as indicated above. Mail the
fingerprint card(s) and a cashier’s check or money order made payable to the Nevada Department of Public
Safety (or NV DPS) to:
Department of Public Safety
Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, NV 89706
7. Include the completed, signed and stamped Agent Applicant Fingerprint Submission Form with the rest of
your agent application to the Department of Taxation Marijuana Enforcement Division.
If any of the required information is missing or incomplete, the request will not be processed by DPS and
may cause delays or possible denial of your agent card application.
12
Nevada Marijuana Enforcement Division
Establishment Information (If owner, officer or board member)
Please type or print legibly. All fingerprints must go to DPS for processing. Electronic submission to DPS
is REQUIRED unless being fingerprinted outside of Nevada.
Applicant
Instructions
Nevada Marijuana Enforcement Division
Agent Applicant Fingerprint Submission Form
Provide this form to the fingerprint technician at the time fingerprints are taken. Submit the
completed, stamped form with your agent card application.
Fingerprint technician: Please ensure that you see a photo ID for identity verification purposes prior to
fingerprinting. Also, please enter the required information in the lower right hand corner and return this form
to the applicant for submission to the Marijuana Enforcement Division.
EYE COLOR
PHYSICAL ADDRESS LINE 1 (ADDRESS ON GOVERNMENT ID)
DATE OF BIRTH
PHYSICAL CITY, STATE ZIPCODE (TOWN, CITY, PROVINCE, POSTAL CODE)
SOCIAL SECURITY NUMBER (optional)
ESTABLISHMENT NAME
CERTIFICATE
NAME (FIRST MIDDLE LAST)
MOBILE PHONE NUMBER
HAIR COLOR
HEIGHT (INCHES)
WEIGHT (LBS)
RACE
ETHNICITY
PHYSICAL ADDRESS LINE 2
FINGERPRINT AGENCY STAMP
GENDER
PLACE OF BIRTH
HOME PHONE NUMBER
FINGERPRINT REPRESENTATIVE SIGNATURE
TCN#
DATE
CITIZENSHIP
ESTABLISHMENT TYPE
ESTABLISHMENT CODE
Reason Fingerprinted
MNU (Account #): 152108
Medical Marijuana Establishments (Check one)
NRS 453A.322
NRS 453A.334
Current Owner/Officer/Board Member
Prospective Owner/Officer/Board Member
Employee/Contractor/Volunteer
NRS 453A.332
Recreational Marijuana Establishments (Check one box if
establishment is both Recreational and Medical, or for Distributors)
NRS 453D
NRS 453D
Current Owner/Officer/Board Member
Prospective Owner/Officer/Board Member
Employee/Contractor/Volunteer
NRS 453D
NOTE: If you work, or will work for a "Dual Licensee" establishment (Medical and
Recreational) you must submit two fingerprint cards; one with the "Reason Fingerprinted" of
NRS 453A, and one with NRS 453D. You will also have to pay DPS's processing fee for
each card.
ORI: NV0131700
13
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Completed 18 July 2020

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