Fillable Hemp Grower Application NYS Hemp Licensing Program 1. (New York State)

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Hemp Grower Application NYS Hemp Licensing Program 1. (New York State)

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PI-421
Page 1 of 2
Updated 12/15/2021
FOR OFFICE USE ONLY
Date Received:
Estab. No.:
License No.:
Fee:
Credit Card Check M.O. Receipt
Reviewed:
Approved:
RICHARD A. BALL
Commissioner
This application is for a 3-year growing license.
Application Fee: $500
NYS Hemp Licensing Program
Hemp Grower Application
Please review the Program Guidance Document and the Application Guidance Document before completing this form.
Please include with this
application all required fees, maps, and background check(s). Incomplete applications will be denied.
1. Business Information. New Application Renewal
Mailing address (if different from above):
2. Contact Information.
3. Business Focus.
4. Experience
*Selling hemp seeds or transplants requires a separate license. Complete and attach the separate application(s) and
include the additional application fee(s) upon submission. (Hemp Seed Retail License | Nursery Grower License)
**Cannabinoid (CBD) processing, manufacturing, and retail licenses are issued by the Office of Cannabis Management.
Business Name:
Federal EIN:
Phone:
Address:
City:
State:
Zip:
Email:
Address:
City:
State:
Zip:
Primary Contact:
Title:
Phone:
Full Name:
Address:
City:
State:
Zip:
County:
Email:
Optional Secondary Contact:
Title:
Phone:
Full Name:
Address:
City:
State:
Zip:
County:
Email:
Check all that apply Additional Fees:
Fiber
Grain/food products (ex: hempseed oil)
Microgreens
Replication/sale of hemp seeds* $100
Nursery Growing (e.g. transplants)* $100
CBD Hemp Growing
Research (cannot sell under this license)
Other:
The Department does not license CBD processing/manufacturing/retail sales**
Did the applicant participate in the NYS Industrial
Hemp Pilot Program between 2016-2021?
YES NO
If yes, provide the state-issued authorization number.
HEMP-G-____________
Does the applicant currently hold a valid Nursery
Grower License from the Department?
YES NO
If yes, provide the state-issued license number.
License No. ____________
PI-421 NYS Hemp Licensing Program
Hemp Grower Application
Page 2 of 2 Updated 12/15/2021
5. Locations. (attach Additional Locations as necessary)
Each indoor and outdoor location must be registered separately even if located at the same address.
Submit with this application maps displaying site boundaries, roads, and access points for each separate growing/storage site.
6. Seed Source and Varieties. (attach additional sheets as necessary)
7. Criminal History.
Submit with this application FBI Identity History Summaries for all key participants as required and defined in 1 NYCRR §159.2
By signing below, I attest that the applicant possesses adequate facilities, equipment, and security measures to grow,
cultivate, and process hemp in connection with its growing and cultivation as required by Agriculture and Markets Law Article
29 §509.6. I understand that the statements made in this application will be accepted for all purposes as the equivalent of an
affidavit and that any false statements made herein, in addition to being the possible basis for a revocation of any license
issued as a result of this application, may be punishable as a misdemeanor under the provisions of Section 210.45 of the
Penal Law of the State of New York.
Site 1:
Outdoor:
acres
OR
Indoor:
square feet
Site Name:
Address:
City:
State:
Zip:
County:
Please provide the GPS coordinates from the center of the field/building in decimal format:
Example: 42.734537, -73.817688
Latitude:
Longitude:
I confirm that I have control over this property through:
Ownership
Lease agreement
Site 2:
Outdoor:
acres
OR
Indoor:
square feet
Site Name:
Address:
City:
State:
Zip:
County:
Please provide the GPS coordinates from the center of the field/building in decimal format:
Example: 42.734537, -73.817688
Latitude:
Longitude:
I confirm that I have control over this property through:
Ownership
Lease agreement
Name:
Address:
City:
State:
Zip:
Varieties:
Has the person responsible for management of hemp or any officer, director, stockholder, or person with
executive managerial control over the entity seeking a license been convicted of a drug-related felony in any court
of the U.S. or any state or territory in the past 10 years? YES NO
If yes, please explain:
Name (Print):
Date:
Signature:
Business Name:
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Hemp Grower Application NYS Hemp Licensing Program 1. (New York State)

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Completed 24 March 2022

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