State of Connecticut
Department of Agriculture
Bureau of Regulatory Services
450 Columbus Blvd, Suite 702 Hartford, CT 06103
Phone: 860-713-2502 Email:
Hemp Seed 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):
Hemp Variety/ Strain
exactly as listed on
seed certification
documents or seed
Seeds or
Name and Address for source of seeds or transplants
Plot name or
number where
hemp will be grown
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
Seed/ Propagule Variety CHANGE ***