Fillable State of Connecticut Department of Agriculture Hemp Grow (State of Connecticut/Department of Administrative Services)

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State of Connecticut Department of Agriculture Hemp Grow (State of Connecticut/Department of Administrative Services)

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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
Hemp Grow Site Modification Request
(rev. 7/25/19)
This form will only be accepted through the DOAG E-License portal. Paper
applications will not be accepted.
The submission of this request form and a subsequent License Agreement Amendment must be executed
prior to the growing, handling, processing, or storage of hemp materials at any location (GPS coordinates)
NOT already listed on your License Agreement.
License Holder:
Grower License #:
Name of Signing Authority (if Business):
Email:
Phone#:
Print
Save
Enter information for the ADDITION of outdoor plots in the cells below.
The Department will assign Plot ID Numbers.
Location 1
New
Plot(s)
Planting Address 1
City
State
Zip
Own/Rent*
GPS Latitude (Decimal
Degrees**)
GPS Longitude (Decimal
Degrees**)
Acres
(DEPT USE ONLY) Plot ID#
Plot 1
Plot 2
Plot 3
Plot 4
Plot 5
Location 2
New
Plot(s)
Planting Address 2
City
State
Zip
Own/Rent*
GPS Latitude (Decimal
Degrees**)
GPS Longitude (Decimal
Degrees**)
Acres
(DEPT USE ONLY) Plot ID#
Plot 1
Plot 2
Plot 3
Plot 4
Plot 5
Enter information for the REMOVAL of requested outdoor plots.
Be sure to include the Grower plot IDs (as they appear on your License Agreement) for each growing site
Grower Plot
ID#
DoAg Plot ID
Address
City
Zip
Outdoor Growing Plot CHANGE
Indicate type of greenhouse production (check all that apply)
Transplants only (either seeded or vegetative cuttings, or seasonal stock plants)
Stock plants, year round
Year-round production with intent to harvest indoor plants
Enter information for the ADDITION of indoor growing locations in the cells below.
The Department will assign Plot ID Numbers.
New
Indoor
Growing
Address 1
Planting Address 1
City
State
Zip
Own/Rent*
GPS Latitude (Decimal
Degrees**)
GPS Longitude (Decimal
Degrees**)
Acres
(DEPT USE ONLY) Plot ID#
Plot 1
Plot 2
Plot 3
Plot 4
New
Indoor
Growing
Address 2
Planting Address 2
City
State
Zip
Own/Rent*
GPS Latitude (Decimal
Degrees**)
GPS Longitude (Decimal
Degrees**)
Acres
(DEPT USE ONLY) Plot ID#
Plot 1
Plot 2
Plot 3
Plot 4
Enter information for the REMOVAL of indoor growing location.
Be sure to include the assigned plot IDs (as they appear on your License Agreement) for each growing site
Grower Plot
ID#
DoAg Plot ID
Address
City
Zip
Greenhouse/Indoor Growing Addresses CHANGE
Enter information for the ADDITION of Drying/Storage address(es) in the cells below
Drying/Storage
Name/ID
Address
City
State
Zip
Own/Rent*
GPS Latitude (Decimal Degrees**)
GPS Longitude (Decimal Degrees**)
(DEPT USE ONLY)
Enter information for the REMOVAL of Drying/Storage address(es) in the cells below
Drying/Storage
Name/ID
Address
City
Zip
By signing my name below, I attest that I am the license holder or the signing authority for 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.
________________________________________________________ Date: _____________________
Individual Licensee, On-Site Manager or Signing Authority Signature
Modify Drying/Storage
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State of Connecticut Department of Agriculture Hemp Grow (State of ConnecticutDepartment of Administrative Services)

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Completed 20 July 2020

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