Fillable GENERAL INFORMATION (Arizona Department of Health Services)

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GENERAL INFORMATION (Arizona Department of Health Services)

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Last updated 10.26.2016 www.azdhs.gov/medicalmarijuana/
MEDICAL MARIJUANA DISPENSARY
REGISTRATION CERTIFICATE RENEWAL APPLICATION
GENERAL INFORMATION
FIEL D S MAR KE D WIT H AN AS T ERI SK (*) A R E REQUIRE D .
Dispensary’s Legal Name*:
Dispensary’s Registration Certificate ID#*:
CHAA #:
Dispensary’s Physical Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County:
State*:
Zip Code*:
Dispensary’s Mailing Address:
City:
County:
State:
Zip Code:
Dispensary’s Transaction Privilege Tax# (issued by Arizona Department of Revenue)*:
Dispensary’s DBA (if applicable):
Applying Entity’s Name*:
E-mail address:
DESIGNATED PRINCIPLE OFFICER OR BOARD MEMBER INFORMATION
List the name of the PO/BM designated to submit dispensary agent registry ID card applications on behalf of the dispensary.
Last Name*:
First Name*:
MI:
Phone Number:
E-mail address:
MEDICAL DIRECTOR INFORMATION
Last Name*:
First Name*:
MI:
License #*:
License Type: MD DO NMD MD(H)
HOURS OF OPERATION*
List the dispensary’s hours of operation during which the dispensary is available to dispense medical marijuana to qualifying
patients and designated caregivers.
Monday
AM PM through
AM PM
Tuesday
AM PM through
AM PM
Wednesday
AM PM through
AM PM
Thursday
AM PM through
AM PM
Friday
AM PM through
AM PM
Saturday
AM PM through
AM PM
Sunday
AM PM through
AM PM
Last updated 10.26.2016 www.azdhs.gov/medicalmarijuana/
MEDICAL MARIJUANA DISPENSARY
REGISTRATION CERTIFICATE RENEWAL APPLICATION
PRINCIPAL OFFICER AND BOARD MEMBER INFORMATION
Provide the following information for each principal officer and board member. Use as many sheets as needed.
Last Name*:
First Name*:
MI:
PO BM
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Has this individual served as a principal officer or board member for a dispensary that has had their dispensary registration certificate
revoked?* YES NO
Is this individual a physician currently providing written certifications for qualifying patients?* YES NO
Is this individual a law enforcement officer?* YES NO
Is this individual employed by or a contractor of ADHS?* YES NO
Last Name*:
First Name*:
MI:
PO BM
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Has this individual served as a principal officer or board member for a dispensary that has had their dispensary registration certificate
revoked?* YES NO
Is this individual a physician currently providing written certifications for qualifying patients?* YES NO
Is this individual a law enforcement officer?* YES NO
Is this individual employed by or a contractor of ADHS?* YES NO
Last Name*:
First Name*:
MI:
PO BM
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Has this individual served as a principal officer or board member for a dispensary that has had their dispensary registration certificate
revoked?* YES NO
Is this individual a physician currently providing written certifications for qualifying patients?* YES NO
Is this individual a law enforcement officer?* YES NO
Is this individual employed by or a contractor of ADHS?* YES NO
Last updated 10.26.2016 www.azdhs.gov/medicalmarijuana/
MEDICAL MARIJUANA DISPENSARY
REGISTRATION CERTIFICATE RENEWAL APPLICATION
DISPENSARY AGENT INFORMATION
Provide the following information for each dispensary agent. Use as many sheets as needed.
Last Name*:
First Name*:
MI:
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Last Name*:
First Name*:
MI:
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Last Name*:
First Name*:
MI:
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Last Name*:
First Name*:
MI:
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Last Name*:
First Name*:
MI:
Date of Birth*:
Dispensary Agent Registry ID#*:
Residence Address*:
*This must be an Arizona address and cannot be a P.O. Box.
City*:
County*:
State*:
Zip*:
Last updated 10.26.2016 www.azdhs.gov/medicalmarijuana/
MEDICAL MARIJUANA DISPENSARY
REGISTRATION CERTIFICATE RENEWAL APPLICATION
SUPPLEMENTAL REQUESTS*
Does the applicant agree to allow the Arizona Department of Health Services (ADHS) to submit supplemental requests for
information? YES NO
Pursuant to A.R.S. § 41.1030(B)(D)(E)(F)
B. An agency shall not base a licensing decision in whole in part on a licensing requirement or condition that is not specifically authorized
by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing
requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement of
condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable
attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation
of this section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or
dismissal pursuant to the Agency’s adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02
A registry identification card or registration certificate issued by the Arizona Department of Health Services pursuant to Arizona Revised
Statutes Title 36, Chapter 28.1 and Arizona Administrative Code Title 9, Chapter 17 does not protect me from legal action by local, city,
state, or federal authorities, including possible criminal prosecution for violations of federal law for the sale, manufacture, distribution, use,
dispensing, possession, etc. of marijuana.
The acquisition, possession, cultivation, manufacturing, delivery, transfer, transportation, supplying, selling, distributing, or dispensing
“medical” marijuana under state law is lawful only if done in strict compliance with the requirements of the State Medical Marijuana Act
(“Act”), Arizona Revised Statutes Title 36, Chapter 28.1 and Arizona Administrative Code Title 9, Chapter 17. Any failure to comply with
the Act may result in revocation of the registry identification card or registration certificate issued by the Arizona Department of Health
Services, and possible arrest, prosecution, imprisonment and fines for violation of state drug laws.
The State of Arizona, including but not limited to the employees of the Arizona Department of Health Services, is not facilitating or
participating in any way with my acquisition, possession, cultivation, manufacturing, delivery, transfer, transportation, supplying, selling,
distributing, or dispensing “medical” marijuana.
If the applicant is issued a dispensary registration certificate, the applicant agrees to not operate the dispensary until the dispensary is
inspected and the applicant obtains an approval to operate from ADHS.
I attest that the information provided to ADHS for this dispensary registration certificate renewal application is true and correct.
__________________________________________________ _________________________________________________
Print Name Title
___________________________________________________ _________________________________________________
Signature Date Signed
_________________________________________________ _________________________________________________
Print Name Title
___________________________________________________ ________________________________________________
Signature Date Signed
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Last updated 10.26.2016 www.azdhs.gov/medicalmarijuana/
MEDICAL MARIJUANA DISPENSARY
REGISTRATION CERTIFICATE RENEWAL APPLICATION
PRINCIPAL OFFICER AND BOARD MEMBER ATTESTATION
SUPPLEMENT FORM
I attest that the information provided to ADHS for this dispensary registration certificate renewal application is true
and correct.
___________________________________________________ _________________________________________________
Print Name Title
___________________________________________________ ________________________________________________
Signature Date Signed
__________________________________________________ _________________________________________________
Print Name Title
___________________________________________________ _________________________________________________
Signature Date Signed
__________________________________________________ _________________________________________________
Print Name Title
___________________________________________________ _________________________________________________
Signature Date Signed
___________________________________________________ _________________________________________________
Print Name Title
___________________________________________________ ________________________________________________
Signature Date Signed
__________________________________________________ _________________________________________________
Print Name Title
___________________________________________________ _________________________________________________
Signature Date Signed
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GENERAL INFORMATION (Arizona Department of Health Services)

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Completed 7 November 2020

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