Fillable Individual Character Competency Form (Commonwealth of Massachusetts)

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Individual Character Competency Form (Commonwealth of Massachusetts)

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The Individual 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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Application of Intent - Character & Competency Form -Page 1
Applicant Corporation
SECTION G. CHARACTER & COMPETENCY FORM
Form for an Individual
INSTRUCTIONS
If you are completing a Character and Competency Form as an individual, please use this “Form for an
Individual.” If you are completing a Character and Competency Form for an entity, please use the “Form for
an Entity.”
A Character and Competency Form must be completed and signed by each of the following individuals:
• Chief Executive Officer;
• Chief Operating Officer;
• Chief Financial Officer;
• Individual responsible for marijuana for medical use cultivation operations;
• Individual responsible for the RMD security plan and security operations;
• Each Member of the Board of Directors;
• Each Member of the Corporation, if any;
• Each individual 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, each individual employee or representative
performing onsite services as Cultivation or Security Manager, or the equivalent, on behalf of a
consulting or contracted company; and
• For entities contributing 5% or more of initial capital to operate the proposed RMD:
o the Chief Executive Officer or Executive Director of the entity; and
o President or Chair of the Board of Directors of the entity.
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.
If the entity contributing 5% or more of initial capital to operate the proposed RMD does not have a Chief
Executive Officer or Executive Director or President or Chair of the Board of Directors, it must identify the
individuals performing the equivalent duties for the entity and submit this form for each said individual.
Applicant Corporation
Application of Intent - Character & Competency Form -Page 2
SECTION A. INDIVIDUAL INFORMATION
Name of Individual
Title
of Individual at Applicant Corporation
Dat
e of Birth of Individual
Res
idential Address of Individual
Appli
cant 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. Have you 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. Have you 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. Have you 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. Have you 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. Have you 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 any entity in which you have served as an executive, officer, corporate member or board member been
the subject of a correction order issued under the laws or regulations of the Commonwealth or other states,
during the time that you were serving as an officer or board member?
Yes No If yes, please explain:
Applicant Corporation
Application of Intent - Character & Competency Form -Page 6
7. Has any entity in which you have served as an executive, officer, corporate member or board member 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 any entity in which you have served as an executive, officer, corporate member or board member 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 in which
you either owned shares of stock or served as an executive, and 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 any entity in which you have served as an executive, officer, corporate member or board member 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 your profession or
occupation or fraudulent practices, including but not limited to fraudulent billing practices?
Yes No If yes, please explain:
10. Has any entity in which you have served as an executive, officer, corporate member or board member 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 the Individual Date Signed
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Individual Character Competency Form (Commonwealth of Massachusetts)

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Completed 27 July 2020

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