Fillable Entity Character Competency Form (Commonwealth of Massachusetts)

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Entity Character Competency Form (Commonwealth of Massachusetts)

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The Entity Character Competency Form (Commonwealth of Massachusetts) form is 8 pages long and contains:

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 1
SECTION G. CHARACTER & COMPETENCY FORM
F
orm for an Entity
INSTRUCTIONS
If you are completing a Character and Competency Form for an entity, please use this “Form for an Entity.” If
you are completing a Character and Competency Form as an individual, please use the “Form for an
Individual.”
A Character and Competency Form must be completed and signed by an authorized signatory of each of the
following entities:
• Entity responsible for marijuana for medical use cultivation operations;
• Entity responsible for the RMD security plan and security operations;
• Each entity known to date that is committed to contributing 5% or more of initial capital to operate the
proposed RMD.
If applicable and known during the application process, where a consulting or contracted company sends an
individual employee or representative to perform onsite services as Cultivation or Security Manager or the
equivalent, the individual who will provide the onsite services must also complete and sign a Character and
Competency Form, in addition to the consulting or contracting company. Please have the individual complete a
“Form for an Individual.”
For entities contributing 5% or more of initial capital to operate the proposed RMD, a Character and
Competency Form must also be completed and signed by the entity’s Chief Executive Officer or Executive
Director and President or Chair of the Board of Directors. Please have each individual complete a “Form for
an Individual.”
Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 2
SECTION A. ENTITY INFORMATION
Name of Entity
Role of Entity at Applicant Corporation
Corporate Address of Entity
Applicant Corporation
Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 3
SECTION B. QUESTIONS
Answer “Yes” or “No” for each question. If you check “Yes,” please provide an explanation.
1. Has the entity ever been convicted of a felony drug offense in Massachusetts, or a like violation of the laws
of another state, the United States, or a military, territorial, or Indian tribal authority?
Yes No If yes, please explain:
2. Has the entity been the subject of any legal or enforcement actions in any state, in the past or pending,
related to the cultivation, processing, distribution, or sale of marijuana for medical purposes?
Yes No If yes, please explain:
Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 4
3. Has the entity been the subject of any past or pending denial, suspension, or revocation of a license or
registration, or the denial of a renewal of a license or registration, for any type of business or profession, by
any federal, state, or local government, or any foreign jurisdiction, including denial, suspension, revocation,
or refusal to renew certification for Medicaid or Medicare?
Yes No If yes, please explain:
4. Has the entity been the subject of any past discipline by, or a pending disciplinary action or unresolved
complaint by, the Commonwealth, or a like action or complaint by another state, the United States or a
military, territorial, or Indian tribal authority with regard to any professional license or registration?
Yes No If yes, please explain:
Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 5
5. Has the entity been the subject of any investigation or discipline for prescribing or distributing controlled
substances or legend drugs other than for therapeutic or other proper medical or scientific purposes?
Yes No If yes, please explain:
6. Has the entity been the subject of a correction order issued under the laws or regulations of the
Commonwealth or other states?
Yes No If yes, please explain:
Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 6
7. Has the entity been the subject of a governmental investigation or enforcement action for lack of compliance
with laws of the Commonwealth relating to taxes and child support?
Yes No If yes, please explain:
8. Has the entity been the subject of a criminal investigation or enforcement action under the laws of the
Commonwealth, or another state, the United States, or a military, territorial, or Indian tribal authority,
including but not limited to action against any health care facility or facility for providing marijuana for
medical purposes, which resulted in conviction, or guilty plea, or plea of nolo contendere, or admission of
sufficient facts?
Yes No If yes, please explain:
Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 7
9. Has the entity been the defendant or subject in any civil or administrative action under the laws of the
Commonwealth, another state, the United States, or a military, territorial, or Indian tribal authority relating
to its professional or occupational field or fraudulent practices, including but not limited to fraudulent
billing practices?
Yes No If yes, please explain:
10. Has the entity been determined by a court or governmental agency or tribunal to have engaged in any
attempt to obtain a registration, license, or approval to operate in any state by fraud, misrepresentation, or
the submission of false information?
Yes No If yes, please explain:
Applicant Corporation ________________________________
Application of Intent - Character & Competency Form -Page 8
SECTION C. ATTESTATION
Signed under the pains and penalties of perjury, I agree and attest that all information included in this form is
complete and accurate.
____________________________________
Signature of Authorized Signatory of Entity Date Signed
Name of Authorized Signatory of Entity
Title of Authorized Signatory of Entity
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Entity Character Competency Form (Commonwealth of Massachusetts)

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Completed 27 July 2020

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