State of Connecticut
Department of Agriculture
Bureau of Regulatory Services
450 Columbus Blvd, Suite 702 Hartford, CT 06103
Phone : 860-713-2502 Email : AGR.Hemp@ct.gov
Applications, supporting documents and payments will only be accepted
through the DOAG E-License portal. Paper applications will not be accepted.
This form is due for every plot (indoor or outdoor). This report is due no more than 15 days prior to the intended
harvest date. (note: if harvest must be expedited due to an urgent situation, e.g. mold, weather, contact the
Department) Following the submission of this form, the grower shall submit a representative sample of the plot(s) to
be harvested to an acceptable laboratory. Harvest shall occur no more than 15 days from the date of the sample. No
harvest is authorized until you receive approval from the Department. Note: An inspector from the Department may be
present at the growing site during the grower’s scheduled sample collection.
Provide harvest info in the table below. The “Grower Plot ID” MUST correspond to the Plot ID used to
name fields or greenhouses on your application or site modification form.
By signing my name below, I attest that I am the license holder or the signing authority of the license
holder, and that this information is accurate and complete. I understand that giving a false statement
is punishable by law under section 53a-157b of the Connecticut General Statutes.
Signature:_________________________________________________ Date: _____________________