Oklahoma Medical Marijuana Authority
09/2020
IMPORTANT NOTE: This form must be submitted by an owner of the commercial entity who is listed as a person of interest in the application.
Commercial Licensee shall cease all operations upon submission of this surrender of its license. Any medical marijuana still in licensee’s possession
must be disposed of in accordance with OAC 310:681-5-10. Any medical marijuana products still in licensee’s possession must be liquidated within
thirty (30) days in accordance with OAC 310:681-5-2(c)(3)(A) or disposed of in accordance with OAC 310:681-5-10.
INSTRUCTIONS: Please complete this form in full with required attachments: (1) commercial license ; (2) a copy of proof of identity of the
individual completing this form.
Mail this form along with required attachments to OMMA, PO BOX 262266, Oklahoma City, OK 73126-2266
COMMERCIAL ENTITY INFORMATION
OWNER FIRST & LAST NAME (person submiting this form) License #
Business Name
License Type GROWER PROCESSOR DISPENSARY TRANSPORTER LABORATORY RESEARCH EDUCATION
PLEASE PRINT OR TYPE CLEARLY
CLOSE OF BUSINESS INFORMATION
surrender of license Form
OMMA Commercial Businesses
Full Name
Email Address Phone Number
Mailing Address
City State Zip
Please provide contact information for at least one person.
Contact information for additional individuals can be
provided on a separate page if needed.
Mailing Address
City State Zip
Please provide the address in which business records will be
retained:
Reason(s) for Surrender of License:
Full Name
Email Address Phone Number
Mailing Address
City State Zip
ATTESTATION
By my signature below I attest to the following:
• The information provided in this form is true and correct;
• I am authorized to submit this Surrender of License Form;
• I understand the business records identified in OAC 310:681-5-6(b) must be retained for at least seven (7) years from the date of creation and these
records are subject to auditing;
• I understand that any medical marijuana still in the possession of the commercial entity shall be disposed of in accordance with OAC 310:681-5-10
and that any medical marijuana products still in possession of the commercial entity shall be either liquidated within thirty (30) days of surrender in
accordance with OAC 310:681-5-2(c)(3)(A) or disposed of in accordance with OAC 310:681-5-10; and
• I understand that monthly reports must be submitted to OMMA until all medical marijuana or medical marijuana products in licensee’s possession at the
time of surrender are lawfully disposed of or liquidated.
Signature Date (mm/dd/yyyy)
