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Rhode Island Department of Business Regulation

Application for Medical MarijuanaResidential Cooperative Cultivation License

Publication Release Date:December 21, 2016

For additional information regarding the Application process, please visit the Department’s website at: http://www.dbr.state.ri.us/

.Questions about the Application and the Application process must be submitted to the

Department by email only to [email protected].

Rhode Island Department of Business RegulationApplication for Medical Marijuana Residential Cooperative Cultivation License

APPLICATION INFORMATION SHEETPlease Note: all Members of the Cooperative Cultivation are required fill out and sign Form 4 below.

PRIMARY APPLICANT(legal name)

DOH REG. ID # STREET ADDRESS CITY, STATE, ZIP PHONE FAX EMAIL

PRIMARY APPLICANT’S DESIGNATED ALTERNATE CONTACT(legal name)

DOH REG. ID # STREET ADDRESS CITY, STATE, ZIP PHONE FAX EMAIL

STREET ADDRESS OF PROPOSED LICENSED PREMISES

CITY, STATE, ZIP PLAT/LOT # OF PROPOSED LICENSED PREMISES

PHONE FAX EMAIL

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If the Cooperative Cultivation is organized as a business entity, please provide the following:BUSINESS NAME (legal name and any d/b/a name(s), if applicable)

Type of entity STREET ADDRESS CITY, STATE, ZIP PHONE FAX EMAIL

PRIMARY APPLICANT SIGNATURESIGNATURE: DATE:

PRIMARY APPLICANT’S DESIGNATED ALTERNATE CONTACT SIGNATURESIGNATURE: DATE:

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Medical Marijuana Residential Cooperative Cultivation License Application

Notice to Applicants who have previously filed a Licensed Cultivator Application: Any Cooperative Cultivation Applicant that has filed Licensed Cultivator application, which is presently pending before the Department, need not submit Forms 1, 2, and 3. By its signature on and submission of this Application, the Cooperative Cultivation Applicant hereby authorizes the Department to review as part of this Application, the corresponding Forms submitted with its Licensed Cultivator Application.

TABLE OF CONTENTSSECTION SECTION TITLE PAGE

NUMBERA Introduction 4B Residential Cooperative Cultivation License Limitations 5C Residential Cooperative Cultivation Possession Limits 5D Important Notices/Disclosures 6E Communications with the Department of Business Regulation 7F How to Apply 7G Review of Application; Denial or Disqualification; Decision 10Form 1 Affirmation Section 11Form 2 Tax Payer Status Affidavit / Identity Form 14Form 3 Mandatory Questions 15Form 4 Disclosure of Membership, Ownership and Management Structure,

Other Interested Parties, and Member Acknowledgement of Limitations

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SECTION A: IntroductionThe Rhode Island Department of Business Regulation (the “Department”) is accepting Applications from qualified Applicants interested in receiving a Medical Marijuana Residential Cooperative Cultivation License.

Pursuant to The Edward O. Hawkins and Thomas C. Slater Medical Marijuana Act, Rhode Island General Laws § 21-28.6-1 et seq., as amended by Rhode Island Public Laws 2016, ch. 142, Article 14 (as so amended, the “Act”), the Department of Business Regulation is responsible for licensing medical marijuana Cooperative Cultivations. The Medical Marijuana Program allows qualifying patients and caregivers to form a Residential Cooperative Cultivation in accordance with the Act and Rules and Regulations Related to the Medical Marijuana Program Administered by the Department of Business Regulation, 161-RICR-300-35-1 (the “Regulations”).

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Please thoroughly review the Regulations which can be found on the Department’s website accessible at the following link: http://www.dbr.state.ri.us/.

SECTION B: Residential Cooperative Cultivation License LimitationsThe rights afforded by a Residential Cooperative Cultivation License, including those related to the cultivation, possession, and transfer of medical marijuana, are strictly limited to those delineated in the Act and the Regulations.

Except for clone cutting procurements permitted under section 1.8(O)(2) of the Regulations, transfer of medical marijuana and medical marijuana products for consideration by the cooperative cultivation or any of its members is strictly limited to transfer among members of that cooperative cultivation and transfer by caregiver members to their associated patients.

Neither the Residential Cooperative Cultivation nor any member thereof, any officer, director, manager/member of any business entity organized for purposes thereof nor any person with managing or operational control of such Residential Cooperative Cultivation may have any material financial interest or control in another Cooperative Cultivation, Licensed Cultivator, Compassion Center, or in a Rhode Island Department of Health approved third party testing provider and vice versa.

SECTION C: Residential Cooperative Cultivation Possession LimitsPursuant to the Act and the section 1.8(J) of the Regulations, Residential Cooperative Cultivations are limited to the amount of marijuana that they may possess as follows:

Tagged Plants: Marijuana plants possessed by a licensed residential cooperative cultivation are limited to the number of plants that are properly tagged in compliance with all provisions of Section 1.9 of the Regulations and as specifically capped in accordance with subsection 1.9(D)(5) therein and in Section 21-28.6-14(a)(6)(ii) of the Act, i.e. twenty four (24) mature plants and twenty four (24) seedlings.

Usable Marijuana: Possession of usable marijuana by a licensed residential cooperative cultivation is limited to the lesser of: (a) ten (10) ounces of dried usable marijuana as capped by R.I. Gen. Laws § 21-28.6-14(6)(ii); and (b) the aggregate total maximum amount of dried usable marijuana that all members of the cooperative cultivation are permitted to possess pursuant to R.I. Gen. Laws § 21-28.6-4(a), (e), and (o). Possession under this paragraph may include any combination of dried usable, edible, or concentrate marijuana that when calculated for total aggregate equivalency amount to dried usable marijuana does not exceed the maximum limit of this paragraph. Possession limits for marijuana possessed in mixed forms shall be calculated as a total equivalent to the maximum limit of dried usable marijuana in pounds in accordance with the equivalency conversion factors delineated in Appendix A of the DOH Regulations (as defined in the Regulations).

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http://www.dbr.state.ri.us/


Wet Marijuana: Pursuant to R.I. Gen. Laws § 21-28.6-14(6)(ii), possession of wet marijuana by a licensed residential cooperative cultivation is limited to the lesser of: (a) fifty (50) ounces of wet marijuana (which, based on the conversion factors adopted in Appendix A of the DOH Regulations, is the equivalent of ten (10) ounces of dried usable marijuana as capped by R.I. Gen. Laws § 21-28.6-14(6)(ii)); and (b) the aggregate total maximum amount of wet marijuana that all members of the cooperative cultivation are permitted to possess.

SECTION D: Important Notices/Disclaimers This Application form is an OFFICIAL DOCUMENT of the Rhode Island Department of Business Regulation. It MAY NOT be altered or changed in any fashion except to fill-in the areas provided with the information that is required. Should any alteration or revision of a question occur, the Department reserves the right to deny the Application in its entirety, or the Department may deem void that specific response and treat that section as unanswered.

The burden of proving an Applicant’s qualifications at all times rests on the Applicant. The Applicant accepts any and all risk of adverse public notice, criticism, emotional distress, or financial loss that may result from any action with respect to this Application. The Applicant expressly waives any and all claims for damages as a result thereof.

The Department may deny an Application that contains a misstatement, omission, misrepresentation, or untruth.

The Department of Business Regulation may request any additional information that it determines is necessary to process and fully vet an Application including inspection of existing grow facilities. The Applicant shall provide all information, documents, materials, and certifications at the Applicant’s own expense.

Should the Department request any additional information that it determines is necessary to process and fully vet an Application, the Applicant shall provide the additional information within the time prescribed. If the Applicant does not provide the requested information within the prescribed time period, the Department will remove the Application from the evaluation process.

The Applicant is not able to contribute additional information after the Application is submitted, unless the Department requests more information.

The Applicant is under a continuing duty to promptly disclose to the Department any changes to the information provided in Form 4 of this application, including any change in the composition of membership, ownership, or other interested parties. The duty to make such additional disclosures shall continue throughout any period of any license that may be granted by the Department.

All notices regarding an Application submission will be sent to the Primary Applicant’s email address provided on this form. The Applicant must immediately notify the Department if the Applicant’s email address changes.

An Applicant who applies for and obtains a license from the Department will be required to submit to inspection as stated in the Act and Regulations.

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After the Application has been submitted, the Applicant may withdraw the submitted Application after written notice to the Department. An Applicant who withdraws their Application forfeits the Application fee which is nonrefundable.

All submissions with and for this Application become the property of the Department and will not be returned.

The Department of Business Regulation’s decision to approve or deny an Application is final.

SECTION E: Communications with the Department All questions about the Application or Application process must be forwarded to the Department of Business Regulation by email only at [email protected] with the subject line “Medical Marijuana Residential Cultivator Application Question.”

Questions and answers of a general nature may be posted on the Department of Business Regulation website so that all Applicants will have access to the same information.

All questions must be sent to the Department of Business Regulation email address only. Violation of this guideline may result in disqualification.

SECTION F: How to ApplyIt is recommended that all potential Applicants thoroughly review the Act and the Regulations governing Cultivator License application procedures and licensee requirements for the Medical Marijuana Program. The Act and Regulations are available on the Department’s website at: http://www.dbr.state.ri.us/.Applicants should use the definitions and descriptive sections of those documents to assist in preparing their Application. The burden of proving an Applicant’s qualifications rests solely on the Applicant.

Applicants must submit one (1) original and three (2) copies of the complete Application package, which shall consist of the items on the following Application Check List.

APPLICATION CHECKLISTItem Required Signatures Included

Yes Not

Included

Application Information Sheet

• Primary Applicant, and• Primary Applicant’s Designated Alternate Contact

Form 1 - Affirmation Section • Primary ApplicantForm 2 - Tax Payer Status Affidavit / Identity Form*

• Primary Applicant, or• If organized as a business entity, an authorized representative of business entity*

Form 3 - Mandatory • Primary Applicant

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http://www.dbr.state.ri.us/


QuestionsForm 4 - Disclosure of

Membership, Ownership and Management Structure,

Other Interested Parties, and Member

Acknowledgement of Limitations

• All Members

Affidavit of Licensed Electrician

n/a

Supporting Documents, including:

(i) If organized as a business entity, the entity’s

certificate or incorporation or organization in Rhode

Island or qualification to do business in Rhode Island;

the articles of incorporation or organization and the

bylaws or operating agreement;

(ii) Evidence of ownership or lease of licensed premises as provided in Section 1.8(F)(6)

(c) of the Regulations;(iii) Description of

parameters/measures to ensure premises not visible from street or public areas

as provided in Section 1.8(F)(6)(b) of the Regulations;

and(iv) Floor plan and security

plan, if applicable.

n/a

List of Supporting Documents

The Applicant should include a list of all supporting documents, which the Applicant submits with their Application (the “Supporting Documents”)

$50.00 Application Fee Cashier’s Check or Money Order made out to the General

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Treasurer, State of Rhode Island

One (1) original and two (2) photocopies of the complete

Application, including all Supporting Documents

* Pursuant to 1.8(E)(1)(d) of the Regulations, if the cooperative cultivation license will held by a business entity, Form 2 - Tax Payer Status Affidavit / Identity shall be completed by an authorized officer of the legal entity rather than the Primary Applicant.

PLEASE NOTE: If an Application is approved, there will be an additional annual license fee of two hundred fifty dollars ($250), which must be paid to the Department prior to issuance of the Residential Cooperative Cultivator license.

The Application is only considered complete if all of these components are submitted. The Applicant is responsible for delivery of all of the Application materials to the Department. Only applications which the Department has determined to be complete shall be eligible for review. An applicant who submits an incomplete Application shall receive written notification from the Department regarding the specific deficiencies and shall be allowed to resubmit additional material to address these deficiencies within a reasonable timeframe.

GENERAL APPLICATION INSTRUCTIONS Read each question carefully. Answer each question completely. Do not leave blank spaces. If a question does not apply, write “Does Not Apply” or “N/A.” If the correct answer to a particular question is “None,” write “None.”

All entries on the Application should be single spaced and typed in 12-point Calibri or Times New Roman font. Signatures on the hard copy Application must be in handwriting, unless otherwise stated by the Department, by the individual providing the information. Do not misstate or omit any material fact(s).

All Supporting Documents, such as business formation papers, tax returns and appendices, as well as the Application forms that comprise an Application package for a license, as listed above, must be submitted at the time of filing this Application. Further, the Applicant is under a continuing duty to promptly notify the Department of Business Regulation if there is a change in the information provided to the Department.

The submittal of an Application constitutes acceptance of the requirements, administrative stipulations, and all of the terms and conditions of this Application. All costs and expenses incurred in submitting an Application in response to this Application will be borne by the Applicant.

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APPLICATION DELIVERY Department of Business Regulation Delivery Address:

Attn: Medical Marijuana Compliance ProgramRhode Island Department of Business Regulation

1511 Pontiac Avenue, Building 68-1Cranston, RI 02920

401-462-9500

SECTION G: Review of Application; Denial or Disqualification; DecisionThe Department of Business Regulation will review submitted Applications based upon the requirements set forth in the Act and Regulations, including operational, safety and security requirements as well as location restrictions.

The Department of Business Regulation may deny any Application or decline to issue a license under any of the following circumstances:

The Application contains a misstatement, omission, misrepresentation, or untruth. The payment of taxes due by the Cooperative Cultivation or any of its members in any

jurisdiction is in arrears. The Application fails to demonstrate to the Department’s satisfaction that the

Cooperative Cultivation will satisfy all requirements under the Regulations and the Act.

Decision Notification: The Department will notify an Applicant in writing of the Department’s approval or rejection of their Application. The Department’s decision to approve or reject an Application for a cooperative cultivation license shall be final. The Department may require an initial inspection of the proposed licensed premises before approving an Application in order to verify information contained in an Application.

Final Inspection, Requirements and Deadlines: Approved Applicants must schedule and receive a final pre-license inspection prior to the Department’s issuance of a cooperative cultivation license. Additionally, payment of the licensing fee, and all other licensing conditions and requirements under the Act and Regulations must be satisfied prior to the Department’s issuance of a license.

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FORM 1Affirmation Section

The Primary Applicant affirms the Cooperative Cultivation’s understanding of the following:1. The burden of proving an Applicant’s qualifications rests on the

party applying for the license.Yes☐

No☐

2. The Department of Business Regulation may deny an Application that contains a misstatement, omission, misrepresentation, or untruth.

Yes☐

No☐

3. An Application shall be complete in every material detail Yes☐

No☐

4. Application fees are non-refundable. Yes☐

No☐

5. The Cooperative Cultivation acknowledges that in filing an Application for a license:

a) The Department of Business Regulation is vested with broad discretion to select the Applicants to be approved for a Cooperative Cultivation License; and

b) The Department of Business Regulation’s decision in approving or denying an Application shall be final.

Yes☐

No☐

6. The following documentation must be displayed prominently on the premises:

a) The Cooperative Cultivation License;

b) An affidavit by a licensed electrician stating that the cultivation has been inspected and is in compliance with any applicable state or municipal housing and zoning codes; and

c) A written acknowledgement signed by all members of the cooperative cultivation of the limitations of the right to use and possess marijuana for medical purposes in Rhode Island.

Yes☐

No☐

7. Any form of manufacturing that uses a heat source or Yes No

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flammable/combustible material must be approved by:

a) the Department; and

b) the State Fire Marshall and/or the local fire department.

☐ ☐

8. The Cooperative Cultivation understands that using any compressed, flammable gas as a solvent in any solvent extraction process, manufacturing or for any other purpose is prohibited.

Yes☐

No☐

9. Except for clone cutting procurements permitted under section 1.8(O)(2) of the Regulations, the Cooperative Cultivation understands that transfer of medical marijuana and medical marijuana products for consideration by the cooperative cultivation or any of its members is strictly limited to transfer amongst members of that cooperative cultivation and transfer by caregiver members to their associated patients.

Yes☐

No☐

10. Pursuant to section 1.8(O)(2)(C), the Cooperative Cultivation must maintain accurate records of all clone cutting transfers.

Yes☐

No☐

11. The Cooperative Cultivation understands that it and its members are limited to cultivating and possessing marijuana only as permitted in the Act and the Regulations.

Yes☐

No☐

12. Neither the Cooperative Cultivation nor any of its members may have any material financial interest or control in another licensed cooperative cultivation, a licensed cultivator, or in a compassion center or in a Rhode Island Department of Health approved third party testing provider and vice versa.

Yes☐

No☐

13. Neither the Cooperative Cultivation nor any of its members are delinquent on the filing of State or Federal taxes. If delinquent, attach a written explanation.

Yes☐

No☐

14. No member may grow medical marijuana at any location other than the licensed cooperative cultivation premises.

Yes☐

No☐

15. No member has had a registration or license suspended, revoked, placed on probationary status or subject to any disciplinary action. If no, attach a written explanation.

Yes☐

No☐

16. No member has been denied a professional license, privilege of taking an examination, or had a professional license or permit

Yes☐

No☐

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disciplined by a licensing authority in Rhode Island or other State. If no, attach a written explanation.

17. The members of the Cooperative Cultivation acknowledge and fully understand that:

a) Marijuana is a Schedule I controlled substance under the Controlled Substances Act of 1970 (21 U.S.C. 801 et seq.);

b) Manufacture, distribution, cultivation, processing, possession, or possession with intent to distribute a Schedule I controlled substance, or conspiring or attempting to do so, are offenses subject to harsh penalties under federal law and could result in arrest, prosecution, conviction, incarceration, fine, seizure of property, and loss of licenses or other privileges; and

c) Any activity regarding Marijuana that does not comply with Rhode Island law or regulations is a violation of State law and could result in arrest, prosecution, conviction, incarceration, fine, seizure of property, and loss of licenses or other privileges.

Yes☐

No☐

18. The members of the Cooperative Cultivation understand that in addition to the above delineated requirements, all activities of cooperative cultivation are subject to the requirements of the Act and the Regulations.

Yes☐

No☐

The undersigned attests that the Cooperative Cultivation Applicant understands and will adhere to the requirements of the Act and the Regulations, including but not limited to those listed above, and that the undersigned has the authority to execute this affirmation on behalf of, and to confirm the Cooperative Cultivation’s agreement to comply with all such requirements.

________________________________________ ________________________Primary Applicant Signature Date

________________________________________Printed Name

FORM 2

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T A X P A Y ER ST A T U S A FF I DAV IT / IDE N TITY F O R M

All persons applying for or renewing any license, registration, permit or other authority (hereinafter called “licensee”) to conduct a business or occupation in the state of Rhode Island are required to file all applicable tax returns and pay all taxes owed to the state prior to receiving a license as mandated by state law (RIGL 5-76) except as noted below.

In order to verify that the state is not owed taxes, licensees are required to provide their Social Security Number or Federal Tax Identification Number as appropriate. These numbers will be transmitted to the Division of Taxation to verify tax status prior to the issuance of a license. This declaration must be made prior to the issuance of a license.

LICENSEE DECLARATION

PLEASE CHECK ONE BOX BELOW OR APPLICATION WILL BE CONSIDERED INCOMPLETE

☐I hereby declare, under penalty of perjury, that I have filed all required state tax returns and have paid all taxes owed.

☐I have entered a written installment agreement to pay delinquent taxes that is satisfactory to the Tax Administrator.

☐I am currently pursuing administrative review of taxes owed to the state.

☐I am in federal bankruptcy. (Case # )

☐I am in state receivership. (Case # )

☐I have been discharged from Bankruptcy. (Case # )

Type of License you’re applying for:

Print Full Name Social Security or Federal Tax Identification Number

Signature Date

FORM 3

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Mandatory Questions

1. Please describe how the applicant(s) will ensure that the cooperative cultivation is a secure indoor facility as required by Regulation. Include a floor plan of the proposed facility and description of planned security measures.

Click here to enter text.

2. Please describe how the Applicant(s) will ensure the cooperative cultivation and its members will comply with all tagging requirements and possession limits under the Act and required by the Regulations.


3. Please describe how the Applicant(s) will ensure divestiture from licensed cultivators and registered compassion centers as required by the Regulations.


4. Please describe how the Applicant(s) owns or leases the proposed licensed premises and/or has permission from the owner to cultivate medical marijuana on the premises.


5. Please describe how the proposed licensed premises complies with applicable municipal zoning laws and include any documentation which confirms this.


6. Please describe how the Applicant(s) will take any and all reasonable efforts to prevent marijuana odors from exiting the licensed premises and altering the environment and odor outside.

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7. Please describe how the Applicant(s) will ensure compliance with the locks and security requirements and ensure that marijuana at the premises is not visible from streets or other public areas as set forth in Sections 1.8(F)(2)(b) and 1.8(F)(6)(b) of the Regulations.

8. Please describe any manufacturing or processing of marijuana that the Applicant(s) intend to engage in under the license and how all manufacturing and processing activities will comply with the Regulations and the Act.


9. Please describe how the Applicant(s) will dispose of marijuana waste material in accordance with Regulations.


10. Please describe how the Applicant(s) will ensure that all marijuana produced under the license will only be provided to cardholders who are eligible to receive it under the Act and how the Applicant(s) will prevent diversion of marijuana to illicit markets.


11. If the Applicant(s) plans to provide clone cuttings to licensed cultivators, please describe how it will do so in accordance with the Regulations and record all transactions.


12. Please describe how the Applicant(s) will post documentation on the licensed premises as required by the Regulations and the Act.

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13. Please describe how the Primary Applicant and Designated Alternate will verify on an ongoing basis that all members of the Cooperative Cultivation are properly registered in compliance with Section 1.8(Q)(2) of the Regulations.


14. Please confirm: (a) the Applicant will self-report its location of the licensed premises to the Rhode Island State Police, or (b) the Applicant’s designation of the Department to report the location on the Applicant’s behalf as described in Section 1.8(F)(5) of the Regulations.



________________________________________Printed Name

FORM 4Disclosure of Membership, Ownership and Management Structure,

Other Interested Parties, and Member Attestations Complete as many copies of this form as necessary to provide all requested information. This form must

be completed and signed by the Primary Applicant and by all Members of the Cooperative Cultivation.

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Part I: MembershipList all Members of the Cooperative Cultivation. Attach a separate sheet if necessary.Member Name DOH Registry ID #

Street Address City State ZIP

Phone Number( )

Email Address

Member Name DOH Registry ID #


Phone Number( )

Email Address



Phone Number( )

Email Address



Phone Number( )

Email Address



Phone Number( )

Email Address



Phone Number( )

Email Address

Part II is only to be completed if the Cooperative Cultivation is organized as a business entity pursuant to Section 1.8(C) of the Regulations.

Part II: Business Ownership and Management StructureList all Members with any ownership interest and/or management or operational control of the Cooperative Cultivation, including all directors, officers, managers/members of the business entity. Attach a separate sheet if necessary. If not organized as a business entity, please write “N/A” in the “name” fields below.

Name Title SSN DOB

DOH Registry ID #

Address City State ZIP Phone Number( )

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Own. % in Applicant

Name Title SSN DOB

DOH Registry ID #


Own. % in Applicant

Name Title SSN DOB

DOH Registry ID #


Own. % in Applicant

Name Title SSN DOB

DOH Registry ID #


Own. % in Applicant

Name Title SSN DOB

DOH Registry ID #


Own. % in Applicant

Name Title SSN DOB

DOH Registry ID #


Own. % in Applicant

Part III: Other Interested PartiesWho, besides the members listed in this application (including persons, firms, partnerships, corporations, limited liability companies, trusts), will loan or give money, inventory, furniture or equipment to, hold a security interest therein, or otherwise receive money or profits from the cooperative cultivation. Attach a separate sheet if necessary. If none, please write “none” in the “name” fields below.

Name Date of Birth SSN/FEIN Interest

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[Attestation of Cooperative Cultivation Members Appears on the Next Page]

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ATTESTATION OF COOPERATIVE CULTIVATION MEMBERS

By signing below, each of the undersigned Members of the Cooperative Cultivation attests to the truthfulness and accuracy of all information contained in this Application. Each Member hereby affirms his/her understanding and agreement that, as a Member of the Cooperative Cultivation, he/she shares equal responsibility with all other Members, including the Primary Applicant, for the Cooperative’s compliance with the Act, the Regulations and all other applicable laws. Each Member acknowledges and agrees that, as a Member of the Cooperative Cultivation, his/her rights to cultivate and possess medical marijuana are strictly limited to those set forth in the Act and the Regulations.

Member’s Legal Name DOH Registry ID Card #


Phone Number( )

Email Address

________________________________________ ________________________Member Signature Date

________________________________________Printed Name



Phone Number( )

Email Address

________________________________________ ________________________Member Signature Date________________________________________



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Printed Name


Phone Number( )

Email Address


________________________________________Printed Name



Phone Number( )

Email Address


________________________________________Printed Name



Phone Number( )

Email Address


________________________________________Printed Name



Phone Number( )

Email Address

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________________________________________Printed Name



Phone Number( )

Email Address


________________________________________Printed Name

Primary Applicant’s Legal Name DOH Registry ID Card #


Phone Number( )

Email Address


________________________________________Printed Name

(Complete as many copies of this form as necessary to provide all requested information and signatures.)

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