Fillable Agent Card Application Quick Guide (Triadex Services)

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Agent Card Application Quick Guide (Triadex Services)

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Agent Card Application
Quick Guide
Thank you for your interest in applying for a Cannabis Establishment Agent Registration Card from the Cannabis
Compliance Board (CCB). This will guide you through the steps and common challenges.
HOW TO APPLY: Applications must be submitted on-line at https://aca-prod.accela.com/NVCCB/. Applications can be
downloaded here: https://ccb.nv.gov/industry/#item-2. For more information, go to: https://ccb.nv.gov/industry/#item-3
PAYMENT AMOUNT: The cost of a cannabis establishment agent card is $150 per category. If you are applying for
multiple categories of cards such as cultivation, production, and dispensary, you must apply for a card for each category
at $150 each.
PAYMENT OPTIONS: Taxation offices will no longer accept walk-in payments. All payments for Agent Cards must be
mailed to the CCB address below. Do not mail to other Taxation offices, and do not leave agent card payments or
applications in the drop boxes. When mailing, include the confirmation page you printed from the portal. If you did not
print the confirmation page, include a note with the name on your application, the categories for which you applied,
and the date you applied. All payments must be in the form of a check, cashiers’ check, or money order payable to
STATE OF NEVADA, and mailed to:
-Standard Mail-
CCB Agent Cards
P.O. Box 1948
Carson City, NV 89701
1
-Overnight Delivery-
CCB Agent Cards
1550 E. College Pkwy Ste., 142
Carson City, NV 89706
STATE OF NEVADA
CANNABIS COMPLIANCE BOARD
www.ccb.nv.gov
1550 College Parkway, Suite 142
Carson City, Nevada 89706
Phone: (775) 687-6299
HON. MICHAEL DOUGLAS
Chair
STEVE SISOLAK
Governor
Grant Sawyer Office Building, Suite 4200
555 E. Washington Avenue
Las Vegas, Nevada 89101
TYLER KLIMAS
Executive Director
CANNABIS AGENT REGISTRATION CARD APPLICANTION
INSTRUCTIONS
• Agents must be at least 21 years of age.
• Agents must not have a criminal record containing excluded felony conviction(s).
• Agents must not have any previous Agent Registration Card revoked.
• Applicants must be in compliance with any court order for support of a child.
• Applicants must provide any additional information requested by the CCB by regulation.
COMPLETION OF APPLICATION & CONTACT: All required Agent Registration or Renewal application forms must
be filled out completely and legibly. Incomplete applications will result in a notice by email or mailing address
provided by the applicant. For questions, write to CCBLicensing@ccb.nv.gov
A complete application includes:
√
Item
Details
Agent Basic Information Document,
Pg. 4
Color copy of the front and back of a government issued ID
Pgs. 5, 6
Attestation Form
Pg. 7
Dispense/Divert Pledge Form
Pg. 8
Passport Photo & Signature
Pg. 9
Payment
$150 per type
Fingerprint Background Waiver Pgs. 10 & 11
PAYMENT AMOUNT: All Fees collected by the CCCB are non-refundable. The cost of a cannabis establishment
agent card is $150 per category. If you are applying for multiple categories of cards such as cultivation,
production, and dispensary, you must apply for a card for each category at $150 each. All payments must be
in the form of a check, cashiers’ check, or money order payable to STATE OF NEVADA. Do not write “cannabis”
or “marijuana on the check or money order.
PAYMENT SUBMISSION: Taxation offices will no longer accept walk-in payments. All payments for Agent Cards
must be mailed to the CCB addresses below. Do not mail to other Taxation offices and do not leave agent card
payments or applications in drop boxes. When mailing, include the confirmation page you printed from the
portal. If you did not print the confirmation page, include a note with the name on your application, the
categories for which you applied, and the date you applied and mailed to:
STANDARD MAIL
CCB Agent Cards
P.O. Box 1948
Carson City, NV 89701
2
FINGERPRINTING: Once you have submitted your application on-line, a Fingerprint Submission Form and
Instructions will be emailed to you. Applicants in Nevada will complete fingerprinting using a LiveScan facility,
return to the online Portal, delete the uploaded fingerprinting document and replace with the completed
Fingerprint Submission Form. Applicants that will be fingerprinted outside Nevada will mail their fingerprinting
documents according to the instructions.
TEMPORARY REGISTRATION AS A CANNABIS ESTABLISHMENT AGENT: A Temporary Registration Approval
letter will be emailed to you shortly after your application has been submitted online and payment has been
received and processed.
DUTIES OF AGENT REGISTRATION CARD HOLDER & ESTABLISHMENT
• Cards expire 2 years from the date of issue. Apply for renewal at least 45 days before expiration to avoid a
lapse in employment. Renew by completing a new application at TaxAgentPortal.nv.gov.
• In order to maintain an active Agent Card, an Affidavit must be filed with the Cannabis Compliance Board 1
year after the issuance of your card. The Affidavit is available on the CCB website CCB.nv.gov.
• Denials or revocations of Agent Registration Cards will include a notification to the applicant of the specific
reasons for the action and will be mailed to the mailing address listed on the application.
• To replace a lost or stolen card, write to
CCBLicensing@ccb.nv.gov within 3 working days of the loss.
• With the exception of Independent Contractor Agents, persons may only work for or volunteer at the
establishment type(s) for which he or she is registered. Independent contractors must insert business name,
address and State Business License Number on the application.
• Agents must be trained prior to working or volunteering. Training is specific for each category of licensing and
includes security, emergency procedures and confidentiality.
• Issuance of a Cannabis Agent Registration Card does not exempt the holder from Federal law. Nevada Revised
Statutes do provide exemptions from state prosecution in some cases. The CCB can not provide legal advice
regarding prosecution.
• Name and Address changes must be registered with the CCB. Complete the Name and Address
Change form
and follow the instructions here: https://ccb.nv.gov/industry/#item-3
3
Cannabis Compliance Board
Agent Basic Information Document
Enter the required information below, print and sign where required.
Please type or print legibly.
n
Applicant
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
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 DISTRIBUTOR, LIST PARENT COMPANY:
SIGNATURE
DATE OF APPLICATION
n
Other Information
n
E
stablishment Category: You may apply for more than one category of agent card, but must
include
$150 for each category you are applying for. Check the categories you wish to apply for.
☐Cultivation ☐Production ☐Dispensary ☐Laboratory ☐Distributor
4
GOVERNMENT ID NUMBER
GENDER ETHNICITY RACE
7/1/20
☐
Contractor Business Name: ______________________________ State Busn. Lic. No.: _____________________
Business Address: __________________________________________________________________________
OTHER NAMES USED
NAME OF ESTABLISHMENT YOU WILL BE WORKING FOR, IF KNOWN: _______________________________________________
If Owner, Officer or Board Member percent of ownership in the entity: __________________%
Cannabis Compliance Board
Color Copy of Front of Identification
In the space below, place a color copy of the front of a valid, unexpired government-issued photo identification
such as a Driver's License. If photocopying, place your ID onto the copy machine and place this sheet on
top of your ID, face down.
5 7/1/2020
Cannabis Compliance Board
Color Copy of Back of Identification
In the space below, insert a color copy of the back of a valid, unexpired government-issued photo identification
such as a Driver's License. If photocopying, place your ID onto the copy machine and place this sheet on top of
your ID, face down.
6 7/1/2020
Cannabis Compliance Board
Applicant Required Attestation Form
Name of Applicant: ___________________________________________ DOB: ________
Mailing Address of Applicant:______________________________________________
City:__________________________________ State: ___________ Zip: ___________
Applicant Attestations
The undersigned hereby attests that:
1. I have not been convicted of an excluded felony offense;
2. I do not currently have an establishment agent registration card, OR I do, and
the registration number is: ___________________________ ;
3. I have not had a Cannabis Establishment Agent Registration Card revoked; and
4. I am in compliance with my court order for support of a child, OR I am not under
any court orders.
5. I am 21 years of age or older.
Signature of Applicant: ________________________________________________ Date: _________
7
7/1/2020
Cannabis Compliance Board
Applicant Dispense/Divert Pledge Form
Name of Applicant: _______________ DOB: __________ SSN: _____________
Mailing Address of Applicant: ____________________________________________
City: _________________________________
State: _______
Zip: _______________
I, the undersigned applicant, pledge not to dispense or otherwise divert cannabis
to any person who is not authorized to possess cannabis in accordance with
provisions of Nevada Revised Statute 678B.340.
Signature of Applicant: ___________________________________
Date: ______
8
7/1/2020
Cannabis Compliance Board
Agent Color
Photograph and Signature
Affix agent photograph and sign in the appropriate boxes below.
Photograph
Attach a standard United States Passport
photograph (2 inches x 2 inches) in the box to the
right. See Passport Photo Requirements. Passport
Photos can be obtained at many Unites States
Post Offices and private businesses such as
Walgreens. Glue the photograph, do not use tape.
Signature
Sign in the box to the right using black ink.
The box is defined by the horizontal and
vertical marks so that the signature can be
scanned without a black border. The box
is 1 inch x 3 inches.
7/1/2020
9
Fingerprint Bac
kground Waiver
As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal
justice purpose (such as an application for employment or a license, an immigration or naturalization matter,
security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided
to you in writing. These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code (U.S.C.)
Section 552a, and Title 28 Code of Federal Regulations (CFR), 50.12, among other authorities.
1. You must be notified by
The Cannabis Compliance Board that your fingerprints will be used to check the
criminal history records of the FBI and the State of Nevada.
2. Authority: The FBI’s
acquisition, preservation, and exchange of fingerprints and associated information is
generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental
authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders,
and federal regulations. Providing your fingerprints and associated information is voluntary; however,
failure to do so may affect completion or approval of your application.
3. Principal Purpose
: Certain determinations, such as employment, licensing, and security clearances, may be
predicated on fingerprint-based background checks. Your fingerprints and associated
information/biometrics may be provided to the employing, investigating, or otherwise responsible agency,
and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next
Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent
fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible
agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the
completion of this application and, while retained, your fingerprints may continue to be compared against
other fingerprints submitted to or retained by NGI.
4. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and
associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your
consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all
applicable Routine Uses as may be published at any time in the Federal Register, including the Routine
Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to,
disclosures to: employing, governmental or authorized non-governmental agencies responsible for
employment, contracting, licensing, security clearances, and other suitability determinations; local, state,
tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national
security or public safety.
5. If you have a crimina
l history record, you should be afforded a reasonable amount to time to correct or
complete the record (or decline to do so) before the officials deny you the employment, license, or other
benefit based on information in the FBI criminal history record. The procedures for obtaining a change,
correction, or update of your FBI criminal history record as set forth at, 28 CFR 16.34 provides for the
proper procedure to do so.
10
7/1/20
6. If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for
review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you
may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this
process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks
and
https://www.edo.cjis.gov .
7. If you decide to chal
lenge the accuracy or completeness of your FBI criminal history record, you should
send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you
may send your challenge directly to the FBI by submitting a request via https://www.edo.cjis.gov
. The FBI
will then forward your challenge to the agency that contributed the questioned information and request the
agency to verify or correct the challenged entry. Upon receipt of an official communication from that
agency, the FBI will make any necessary changes/corrections to your record in accordance with the
information supplied by that agency. (See 28 CFR 16.30 through 16.34.)
8. You have the r
ight to expect that officials receiving the results of the fingerprint-based criminal history
record check will use it only for 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.
9. I hereby authorize the C
annabis Compliance Board to submit a set of my fingerprints to the Nevada
Department Public Safety, Records Bureau for the purpose of accessing and reviewing State of Nevada and
FBI criminal history records that may pertain to me.
10. I hereby release f
rom 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 t
his authorization for release of information by photocopy, facsimile or similar process, shall
for all purposes be as valid as the original.
In consideration fo
r processing my application I, the undersigned, whose name and signature voluntarily appears
below; do hereby and irrevocably agree to the above.
Last Name First Name Middle
Applicant’s Name:
PLEASE PRINT
Applicant’s Signature:
Date:
11
7
/1/
20
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