Applicant Corporation
Management and Operations Profile – Employment and Education Form
SECTION D. EMPLOYMENT AND EDUCATION FORM
This Employment and Education form must be completed and signed by each of the following individuals:
The applicant’s Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, individual
responsible for marijuana for medical use cultivation operations, and individual responsible for the RMD
security plan and security operations. If the applicant does not have a Chief Executive Officer, Chief Operating
Officer, or Chief Financial Officer, it must identify the individuals performing the equivalent duties for the
Applicant and submit this form for each said individual. Submit one Employment and Education form for each
of the above individuals when submitting a Management and Operations Profile to the Department of Public
Health.
Name of Individual
Residential Address of Individual
T
itle of Individual (at Applicant Corporation)
N
ame of Applicant Corporation
H
ighest Education Attained – Institution, Degree, and Year
P
ast 10 Years of Employment by Employer, Title and Time Period. List chronologically, beginning with most
recent employment. Add more forms if space is needed for additional employment history entries.
