Fillable North Carolina Industrial Hemp Commission (Information Technology Services)

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North Carolina Industrial Hemp Commission (Information Technology Services)

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North Carolina Industrial Hemp Commission
APPLICATION TO CULTIVATE INDUSTRIAL HEMP
as part of the NORTH CAROLINA INDUSTRIAL HEMP RESEARCH PILOT PROGRAM
Version 02.2017 pg. 1
PRINT NAME (Last, First, Middle):
DATE:
1. NAME (Last, First, Middle)
RESIDENCE ADDRESS
MAILING ADDRESS (if different)
EMAIL ADDRESS
PRIMARY PHONE (cell or home)
SECONDARY PHONE (cell or home)
BUSINESS NAME (if applicable)
BUSINESS ADDRESS
BUSINESS PHONE
BUSINESS ADDITIONAL PHONE
2. TYPE OF LICENSE APPLIED FOR
□ Research With Intent to Market
□ Research Only (university or government agency only)
3. DURATION OF LICENSE APPLIED FOR
□ One Year
□ Three Years
RESEARCH PURPOSE
Check only the boxes below that correspond with the Authorized Research Purpose (established by G.S. 106-568.) of
your intended planting. This section applies to all intended planting of fields or greenhouses. You will be required to
provide an acceptable report of the results of your planting for each of the purposes selected before the following
year’s license would be issued. Only one purpose is required and additional purposes may be subject to additional
documentation at the request of the Industrial Hemp Commission.
(1) Studying and investigating marketplace opportunities for hemp products to increase the job base in the State by means of
employment related to the production of industrial hemp.
(2) Studying and investigating methods of industrial hemp cultivation that are best suited to soil conservation and restoration.
(3) Overseeing and analyzing the growth of industrial hemp by licensed growers for agronomy research and analysis of required
soils, growing conditions, and harvest methods relating to the production of various varieties of industrial hemp that may be
suitable for various commercial hemp products.
(4) Conducting seed research on various types of industrial hemp that are best suited to be grown in North Carolina, including
seed availability, creation of North Carolina hybrid types, and in-the-ground variety trials and seed production. The Commission
may establish a program to recognize certain industrial hemp seeds as being North Carolina varieties of hemp seed.
(5) Studying the economic feasibility of developing an industrial hemp market in various types of industrial hemp that can be
grown in the State, including by commercial marketing and sale of industrial hemp.
(6) Reporting on the estimated value-added benefits, including environmental benefits, to North Carolina businesses of an
industrial hemp market of North Carolina-grown industrial hemp varieties.
(7) Studying the agronomy research being conducted worldwide relating to industrial hemp varieties, production, and use.
(8) Researching and promoting on the world market industrial hemp and hemp seed that can be grown in the State.
(9) Promoting research into the development of industrial hemp and commercial markets for North Carolina industrial hemp
and hemp products.
(10) Studying the feasibility of attracting federal or private funding for the North Carolina industrial hemp research program.
(11) Studying the use of industrial hemp in new energy technologies, including electricity generation, biofuels, or other forms of
energy resources; the growth of industrial hemp on reclaimed mine sites; the use of hemp seed oil in the production of fuels; and
the production costs, environmental issues, and costs and benefits involved with the use of industrial hemp for energy.
North Carolina Industrial Hemp Commission
APPLICATION TO CULTIVATE INDUSTRIAL HEMP
as part of the NORTH CAROLINA INDUSTRIAL HEMP RESEARCH PILOT PROGRAM
Version 02.2017 pg. 2
PRINT NAME (Last, First, Middle):
DATE:
Please sign and attest to the following statement:
If approved to cultivate industrial hemp in the North Carolina Industrial Hemp Pilot Program, I agree to pursue the
above checked research purpose established by G.S. 106-568.55, collect data that meets the purpose, and report the
results to North Carolina State University, North Carolina Agricultural &Technical State University, as well as to the
North Carolina Industrial Hemp Commission on an annual basis in a manner of which I will be informed after receiving
the license. I understand that failure to do so will result in revocation of this license and make me ineligible for future
licenses until an acceptable report is received. Further, I understand that by signing below, this constitutes a written
agreement with North Carolina State University, North Carolina Agricultural &Technical State University for my
cooperation with them to provide research data and information and to be available and willing to provide additional
information to clarify my reported information and data.
Print Full Name: Sign:
INTENDED PLANTING INFORMATION
4. Size of Intended Planting Area
A licensee must pay a $250 initial fee in addition to an
annual fee of $250 for less than 50 acres or $500 for
more than 50 acres, as well as a $2/acre or $2/1,000
square feet of greenhouse fee.
Acres
Greenhouse (sq. feet)
5. County of Intended Planting
6. GPS Coordinates of each intended
planting in decimal degrees (Ex. lat
34.62273° lon -76.52456°)
Provide a copy of the
field map to locate
the center of the planting area.
7. Names of Intended variety(s)
8. Origin of Intended seed
(country or state)
9. Certifying agency for variety(s) (if
applicable or non-certified if none)
10. Type of certification for each variety
(breeder, foundation, registered, certified,
non-certified, etc.).
Please sign and attest to the following statement:
Under penalty of law, I attest that the variety or varieties of industrial hemp seed and transplants shall include a
certifying tag of varietal purity issued by NCCIA or another official certifying agency as defined in G.S. 106-277.2(23);
or seed or transplants have accompanying documentation of being produced by a licensed grower within the state of
production, and have accompanying documentation that the crop from which the seed or transplants were harvested
had a THC analysis of 0.3% or less by dry weight.
Print Full Name: Sign:
North Carolina Industrial Hemp Commission
APPLICATION TO CULTIVATE INDUSTRIAL HEMP
as part of the NORTH CAROLINA INDUSTRIAL HEMP RESEARCH PILOT PROGRAM
Version 02.2017 pg. 3
PRINT NAME (Last, First, Middle):
DATE:
INTENDED MARKET
(for “Research With Intent to Market” application only)
11. Intended marketable part of the plant
(Check all that apply)
□ Seed
□ Fiber
□ Hurd
□ Cannabinoids (not including THC)
12. Name and address of each entity who
has tentatively or contractually agreed to
purchase each of the checked plant parts
in 11.
BONA FIDE FARMER CERTIFICATION
13. Please check the appropriate box to
the right and attach the documentation to
this application to demonstrate the
applicant was a bona fide farmer
according to its most recent tax filing.
For individual filers, Schedule F of the Form 1040, U.S. Individual
Income Tax Return
For S corporation filers, Page 1 and Schedule B, of the Form 1120S,
U.S. Income Tax Return for S Corporation
For C corporation filers, Page 1 and Schedule K, of the form 1120, U.S.
Corporation Income Tax Return
For partnership filers, Page 1 of the Form 1065, U.S. Return of
Partnership Income and Schedule F of the Form 1040, U.S. Individual
Income Tax Return
STORAGE OF HARVESTED PLANT PARTS
14. County of each intended storage area /
structure for harvested plant parts.
15. GPS Coordinates of each intended
storage area / structure for harvested
plant parts. (Ex. lat 34.62273° lon -
76.52456°)
Provide a copy of the location map to
locate the storage area / structure for
harvested plant parts.
This is the end of information collection for the application. The following page is the agreement and attestation page
required to process this application. Be sure to complete as instructed and sign the agreement page included with
the application. It is vital you complete every portion of this application including the space provided for your printed
name and date at the bottom of each page.
The application’s approval or rejection will be notified by mail if your application is approved. You will then be
required to complete an acceptance document and return that with the designated fees within 30 days of your
approval. After an approval, and your acceptance documents and check have been received for processing you will
be issued a license by the North Carolina Industrial Hemp Commission.
North Carolina Industrial Hemp Commission
APPLICATION TO CULTIVATE INDUSTRIAL HEMP
as part of the NORTH CAROLINA INDUSTRIAL HEMP RESEARCH PILOT PROGRAM
Version 02.2017 pg. 4
PRINT NAME (Last, First, Middle):
DATE:
Application continue on page 4
READ AND SIGN BELOW
Please read each of the following sections. Check each box to affirm that you have read the terms set out and that
you agree to be licensed contingent to the terms. Sign the bottom of the form to agree to all of the terms, below.
ACCESS FOR SAMPLING
I agree to provide access to the cultivated sites and storage facilities for sampling of industrial hemp at any time and for any
reason to the North Carolina Department of Agriculture and Consumer Services and to any State Bureau of Investigation or law
enforcement agency with jurisdiction in the area. I understand I am responsible for the cost of all laboratory analytical services.
AGREEMENT TO MONITOR AND DESTROY VOLUNTEER HEMP PLANTS
For three years following the cultivation of industrial hemp on the site(s) identified on this application, I agree to
monitor the site(s) identified on this application and the surrounding area for volunteer, or feral hemp plants, and
immediately destroy volunteer, or feral hemp plants, in the areas identified above, at my own cost and expense.
AGREEMENT TO MAINTAIN RECORDS
I agree to maintain all records, including but not limited to those for agronomics, contracts, sampling, storage,
expenses, transportation and delivery, and income, from my cultivation of industrial hemp pursuant to the permit
issued by the North Carolina Department of Agriculture and Consumer Services for the duration of the permit while
the permit is valid and for three years thereafter. Further, I agree to produce these records upon request of the North
Carolina Industrial Hemp Commission, the North Carolina Department of Agriculture and & Consumer Services, North
Carolina State University, North Carolina Agricultural &Technical State University, or law enforcement.
AGREEMENT TO NOTIFY PLANT INDUSTRIES
I agree to notify the Plant Industry Division (PID)of NCDA&CS and the North Carolina Industrial Hemp Commission
(Commission) if there are any changes or deviations from the intentions stated in the license within one month of a
known change or deviation.
I agree to notify the PID and the Commission if there are any changes to the license holders address within one
month of a change for the duration of the license.
DISCLOSURE OF CRIMINAL CONVICTIONS Pursuant to N.C. Gen. Stat. § 106-568.56) and N.C. Gen. Stat.§ 106-568.57,
providing the Commission with false or misleading information subjects an applicant to civil and/or criminal penalties.
Participation in the North Carolina Industrial Hemp program does not authorize or enable participants to violate United States
DEA or other federal rules and regulations.
I have had no felony convictions in the prior 10 years.
I have had no drug-related or controlled substances felony conviction at any time.
I disclose the date(s) and location(s) of any conviction of any criminal offense (other than misdemeanor traffic
offenses) committed in any jurisdiction. I acknowledge that failure to comply with this requirement in a complete
and truthful manner shall be grounds for denial, suspension or revocation of a license, as may be determined by the
Commission.
Select one: none to report date and location and conviction details included in space provided
ACKNOWLEDGEMENT
I acknowledge that licensure requires approval by the North Carolina Industrial Hemp Commission. The license fees will be
based upon the information submitted in this application and I have read the fee calculation details described in Item 4. I will
return the signed acceptance form and an original bank check to fully pay the required fees as established in the rules for
licensure within 30 days of the date of issuance of licensure or before I take possession of the seed or transplants, whichever is
earlier.
Print Full Name: Sign:
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North Carolina Industrial Hemp Commission (Information Technology Services)

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Completed 14 August 2020

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