Fillable Remittance Form Management And Operations (Commonwealth of Massachusetts)

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Remittance Form Management And Operations (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Amount Enclosed $_
Application Fee, Management and Operations Profile
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
Medical Use of Marijuana Program
99 Chauncy Street, 11
th
Floor, Boston, MA 02111
CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH
Commissioner
Tel: 617-660-5370
www.mass.gov/medicalmarijuana
Remittance Form
Registered Marijuana Dispensary Application Fee
Please remit this form with your bank/cashier’s check payable to
“The Commonwealth of Massachusetts” for proper posting of your payment
Date
Name of Applicant Corporation
MAILING ADDRESS OF APPLICANT CORPORATION
Address
City
State Zip Code
CONTACT PERSON
First Name
Last Name
Email Address
Phone Number
Bank/Cashier’s Check Enclosed
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Remittance Form Management And Operations (Commonwealth of Massachusetts)

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Completed 26 July 2020

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