Fillable Form Instructions: Marijuana Business Individual History Form (Oregon)

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Form Instructions: Marijuana Business Individual History Form (Oregon)

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Marijuana Business Individual History Form
Form Instructions
Marijuana Business Individual History Form Instructions Revised 20201015
What is this form?
Use this form to provide personal history information for each individual who qualifies as an “applicant” for a
marijuana license, as described in OAR 845-025-1045.
Each person must complete and sign their own history form.
Who needs to complete a Marijuana Business Individual History form?
Everyone who is an “applicant” for a license as described in OAR 845-025-1045, must fill out an Individual
History form.
The Commission may request that other individuals with a financial interest in the business complete an
Individual History form. Unless specifically requested to do so by your license investigator, do not submit any
Individual History forms for individuals who are not applicants and have only a financial interest in the
business.
I know I have to submit fingerprints. How do I do this?
Do not submit fingerprints until OLCC requests that you do so.
If you have not previously submitted fingerprints for a recreational marijuana license, OLCC staff will reach out
to the primary contact for the license application and request that you do so. This may happen when OLCC
reaches out to confirm whether the license application is ready to move forward, or when the application is
assigned to a license investigator.
If you have previously submitted fingerprints for a recreational marijuana license application, you will not
typically need to submit new fingerprints as part of the application process for subsequent applications. After a
license is issued, OLCC may exercise its discretionary authority under OAR 845-025-1080 to require a
licensee to submit new fingerprints.
OREGON LIQUOR CONTROL COMMISSION
Marijuana Business Individual History Form
[FORM MJ 17-1010] mj_app_ih (20201015) Page 1 of 1
Section 1 – Individual History Statement
Name:
first name
middle initial
last name
Date of Birth:
/ /
Gender:
Male
Non-Binary
Month
Day
Year
Which of the following best
describes you? You may
choose to opt-out of responding.
Female
Opt-Out
Mailing Address:
City:
State:
ZIP:
Contact Phone:
Contact Email:
Social Security
Number:
If you have a social security number, this
field is required. See disclosure below.
I do not have a Social
Security Number.
*SOCIAL SECURITY NUMBER DISCLOSURE: As part of your application for an initial or renewal license, Federal and
State laws
require you
to provide your Social Security Number (SSN) to the Oregon Liquor Control Commission (OLCC) for
child
support enforcement purposes (42
USC § 666(a)(13) & ORS 25.785). If you are an applicant or licensee and fail to provide
your
SSN, the OLCC may refuse to process your
application. Your SSN will be used only for child support enforcement
purposes
unless you confirm your agreement that OLCC can use it for
administrative purposes as well.
Based on our authority under ORS 475B.040 and OAR 845-025-1080(2), we are requesting your voluntary consent to use
your SS
N for the
following administrative purposes only: to positively confirm your identity during the criminal records check. OLCC will not deny you any rights,
benefits
or
privileges otherwise provided by law if you do not consent to use of your SSN for these administrative purposes (5 USC§
552(a)).
Please
check the appropriate box next to the social security field indicating whether you consent or do not consent.
Yes
No
Do you consent to use of SSN for purposes of confirming identity during a criminal records check?
Have you ever been convicted of a felony?
(If yes, attach an explanation. A conviction will not necessarily prevent you from obtaining a license.)
Do you have any arrests or citations for misdemeanor or felony changes that are not resolved?
(If you are arrested, cited, or convicted after completing this document but before receiving an OLCC license, you must
immediately notify your assigned investigator and submit a revised Individual History form. Failure to do so may result in
license denial or cancellation.)
Please list the business name and license number or premises number of every OLCC liquor license or marijuana license
(including research certificate or retail liquor agent) that you have applied for or received. This includes having a financial
interest or ownership interest in a legal entity that applied for or held the license.
Name of any business under which you have applied for or held any OLCC marijuana or liquor license:
Section 2 – Acknowledgement
You must sign your own form. You cannot have your attorney or a person with power of attorney sign your form.
I affirm that my answers are true and correct. I understand that if my answers are not true and correct that the OLCC may deny my
application. I understand that I must notify the Commission within 24 hours if I am arrested, cited or convicted for any misdemeanor or
felony after submitting this form.
Signature:
Date:
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Form Instructions: Marijuana Business Individual History Form (Oregon)

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Completed 21 February 2021

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