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What is this form? This application certifications form (Alaska Department of Commerce, Community, and Economic Development)

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[Form MJ-00] (rev 09/27/2018) Page 1 of 3
Alaska Marijuana Control Board
Form MJ-00: Application Certifications
Alcohol and Marijuana Control Office
550 W 7
th
Avenue, Suite 1600
Anchorage, AK 99501
marijuana.licensing@alaska.gov
https://www.commerce.alaska.gov/web/amco
Phone: 907.269.0350
☐ ☐
What is this form?
This application certifications form is required for all marijuana establishment license applications. Each person signing an
application for a marijuana establishment license must declare that he/she has read and is familiar with AS 17.38 and 3 AAC 306.
This form must be completed and submitted to AMCO’s main office by each proposed licensee (as defined in
3 AAC 306.020(b)(2)) before any license application will be considered complete.
Enter information for the business seeking to be licensed, as identified on the license application.
Licensee:
License Number:
License Type:
Doing Business As:
Premises Address:
City
:
State:
ZIP:
Enter information for the individual licensee.
Name:
Title:
Ownership and financial interest in other licenses: Yes No
Do you currently have or plan to have an ownership interest in, or a direct or indirect financial interest in
another marijuana establishment license?
If “Yes”, which license numbers (for existing licenses) and license types do you own or plan to own?
Section 1 – Establishment Information
Section 2 – Individual Information
Section 3 – Other Licenses
[Form MJ-00] (rev 09/27/2018) Page 2 of 3
Alaska Marijuana Control Board
Form MJ-00: Application Certifications
Alcohol and Marijuana Control Office
550 W 7
th
Avenue, Suite 1600
Anchorage, AK 99501
marijuana.licensing@alaska.gov
https://www.commerce.alaska.gov/web/amco
Phone: 907.269.0350
Read each line below, and then sign your initials in the box to the right of each statement: Initials
I certify that I have not been convicted of a felony in any state or the United States, including a suspended imposition of
sentence, for which less than five years have elapsed from the time of the conviction to the date of this application.
I certify that I am not currently on felony probation or felony parole.
I certify that I have not been found guilty of selling alcohol without a license in violation of AS 04.11.010.
I certify that I have not been found guilty of selling alcohol to an individual under 21 years of age in violation of 04.16.051
or AS 04.16.052.
I certify that I have not been convicted of a misdemeanor crime involving a controlled substance, violence against a
person, use of a weapon, or dishonesty within the five years preceding this application.
I certify that I have not been convicted of a class A misdemeanor relating to selling, furnishing, or distributing marijuana
or operating an establishment where marijuana is consumed within the two years preceding this application.
I certify that my proposed premises is not within 500 feet of a school ground, recreation or youth center, a building in
which religious services are regularly conducted, or a correctional facility, as set forth in 3 AAC 306.010(a).
I certify that my proposed premises is not located in a liquor licensed premises.
I certify that I meet the residency requirement under AS 43.23 for a permanent fund dividend in the calendar year in
which I am initiating this application.
I certify that all proposed licensees (as defined in 3 AAC 306.020(b)(2)) have been listed on my online marijuana
establishment license application. Additionally, if applicable, all proposed licensees have been listed on my
application with the Division of Corporations.
I certify that I understand that providing a false statement on this form, the online application, or any other form provided
by AMCO is grounds for denial of my application.
Section 4 – Certifications
[Form MJ-00] (rev 09/27/2018) Page 3 of 3
Alaska Marijuana Control Board
Form MJ-00: Application Certifications
Alcohol and Marijuana Control Office
550 W 7
th
Avenue, Suite 1600
Anchorage, AK 99501
marijuana.licensing@alaska.gov
https://www.commerce.alaska.gov/web/amco
Phone: 907.269.0350
Read each line below, and then sign your initials in the box to the right of each statement: Initials
I certify and understand that I must operate in compliance with the Alaska Department of Labor and Workforce
Development’s laws and requirements pertaining to employees.
I certify and understand that I must operate in compliance with each applicable public health, fire, safety, and tax code
and ordinance of this state and the local government in which my premises is located.
Read each line below, and then sign your initials in the box to the right of only the applicable statement: Initials
Only initial next to the following statement if this form is accompanying an application for a marijuana testing facility license:
I certify that I do not have an ownership in, or a direct or indirect financial interest in a retail marijuana store, a marijuana
cultivation facility, or a marijuana products manufacturing facility.
Only initial next to the following statement if this form is accompanying an application for a retail marijuana store, a marijuana
cultivation facility, or a marijuana products manufacturing facility license:
I certify that I do not have an ownership in, or a direct or indirect financial interest in a marijuana testing facility license.
All marijuana establishment license applicants:
As an applicant for a marijuana establishment license, I declare under penalty of unsworn falsification that I have read and am familiar
with AS 17.38 and 3 AAC 306, and that the online application and this form, including all accompanying schedules and statements, is
true, correct, and complete.
________________________________________ ________________________________________
Signature of licensee Notary Public in and for the State of Alaska
________________________________________ My commission expires: ____________________
Printed name of licensee
Subscribed and sworn to before me this _____ day of _________________________, 20_____.
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Completed 5 May 2021

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