Fillable City of Piedmont Commercial Marijuana Establishment (CITY OF PIEDMONT)

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City of Piedmont Commercial Marijuana Establishment (CITY OF PIEDMONT)

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The City of Piedmont Commercial Marijuana Establishment (CITY OF PIEDMONT) form is 1 page long and contains:

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City of Piedmont
Commercial Marijuana Establishment
Expires: December 31
st
of each year
Please check all that apply for your business:
License Category
Initial Fee
Renewal Fee
Commercial Grower
$1,500.00
$1,500.00
Retailer
$600.00
$600.00
Processor
$2,500.00
$2,500.00
Required Material
□ Fee based on fee schedule
□ Copy of Valid Driver’s License
□ Copy of State Tax Commission License
□ City and State approved facilities
□ Copy of Valid Oklahoma Medical Marijuana Authority License
Date: _____________________ Owner’s Name: __________________________________________________
Company Name: _____________________________________________________________________________
Physical Addresses
Street: _______________________________________
City: _________________________________________
State: _____________ Zip Code: _______________
Mailing Address (If Different)
Street: _______________________________________
City: _________________________________________
State: _____________ Zip Code: _______________
Phone Number: _________________________ Cell Phone Number: _____________________________
Fax Number: __________________________ E-Mail Address: ____________________________________
Printed Name
Date
****************************OFFICE USE ONLY*****************************
☐
Paid
☐
Unpaid
Receipt #: ______________________
_________________________________________________
Community Development
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City of Piedmont Commercial Marijuana Establishment (CITY OF PIEDMONT)

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Completed 14 July 2020

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