ohio medical marijuana dispensary application agri-med ... · demographic information(primary...
TRANSCRIPT
Ohio Medical Marijuana Dispensary Application
AGRI-MED ENTERPRISES, INC. Application ID 1038
Demographic Information(Business Contact)
A-1.1 Business Name, as it appears on the Applicant’s certificate of incorporation, charter, bylaws,partnership agreement or other legal business formation documents
A-1.2 Other trade names and DBA (doing business as) names
A-1.3 Business Street Address
A-1.4 City
A-1.5 State
A-1.6 Zip Code
A-1.7 Phone
A-1.8 Email
Agri-Med Enterprises, Inc.
No response provided by applicant
6660 Doubletree Ave. Suite 8
Columbus
OH
43229
8332474633
Demographic Information(Primary Contact/Registered Agent)
A-2.1 Please select: Primary Contact, or Registered Agent for this Application
A-2.2 First Name
A-2.3 Middle Name
A-2.4 Last Name
A-2.5 Street Address
A-2.6 City
A-2.7 State
A-2.8 Zip Code
A-2.9 Phone
A-2.10 Email
PRIMARY CONTACT
Charles
R
Griffith
522 N. State Street
Westerville
OH
43082
6148904543
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Demographic Information(Applicant Organization and Tax Status)
A-3.1 Select One
A-3.1A If other, explain
A-3.2 State of Incorporation or Registration
A-3.3 Date of Formation
A-3.4 Business Name on Formation Documents
A-3.5 Federal Employer ID number
A-3.6 Ohio Unemployment Compensation Account Number
A-3.7 Ohio Department of Taxation Number (if Applicant is currently doing business in Ohio)
A-3.8 Ohio Workers’ Compensation Policy Number (if Applicant is currently doing business in Ohio)
A-3.9 The Applicant attests that workers’ compensation insurance will be obtained by the time theState of Ohio Board of Pharmacy determines the Applicant to be operational under the Act andregulations.
A-3.10 Has the Applicant operated and conducted business in any jurisdiction other than Ohio in thepast three years? If you select "Yes", answer question A-3.10.1 below.
A-3.10.1 If "Yes" to question A-3.10, for each instance relevant to question A-3.10, provide thefollowing:
Legal Business NameBusiness AddressFederal Employee ID Number
S-Corporation
N/A
OH
05/09/2017
Agri-Med Enterprises, Inc.
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
YES
NO
N/A
Demographic Information(Economically Disadvantaged Business)
A-4.1 The Applicant attests that at least fifty-one percent of the business, including corporate stock if acorporation, is owned by persons who belong to one or more of the groups set forth in this division, andthat those owners have control over the management and day-to-day operations of the business andan interest in the capital, assets, and profits and losses of the business proportionate to theirpercentage of ownership. ORC 3796.10 NO
Demographic Information(District Information )
A-5.1 Please select to indicate the medical marijuana dispensary Ohio district for which you areapplying for a dispensary license
A-5.2 Please select to indicate the medical marijuana dispensary Ohio county for which you areapplying for a dispensary license
SOUTHEAST-3
Franklin
Demographic Information(Prospective Associated Key Employees Details)
Item 1 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Alexius
James
Dorsey
No response provided by applicant
Entrepreneur
President
$225000
1500
Common
15%
15%
PERSON EXERCISING SUBSTANTIAL CONTROL
15% if capital required for business organization and assemble team
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
5727 Liberty Road
Powell
OH
43065
8332474633
No response provided by applicant
40
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 2 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Victor
Brandon
Thompson
No response provided by applicant
Physician
Chairman
0
700
Common
7%
7%
BOARD MEMBER
Capital equal to Percentage. 7% of capital required for business. Focus and development.
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
7000 Olentangy River Road
Delaware
OH
43015
8332474633
No response provided by applicant
15
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 3 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Syed
Saqib
Ali
M.D., M.B.A.
Physician
Chief Medical Officer
0
600
Common
6%
6%
OFFICER
6% of capital required for business. Medical direction.
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
8333 Beacon Place
Cleveland
OH
44103
2169659151
No response provided by applicant
39
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 4 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Joyce
Elaine
Griffith
No response provided by applicant
Chief Financial Officer
Chief Financial Officer
$95,000
600
Common
6%
6%
OWNER
6% of capital required for business. Establish service.
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
361 Cornhill Court
Westerville
OH
43081
6147360555
No response provided by applicant
39
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 5 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Jatin
Rajendra
Patel
No response provided by applicant
Chief Operating Officer/Chief Financial Officer
Chief Operations Officer
0
0
0
0%
0
OFFICER
0
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
7526 Wayside Avenue
Delaware
OH
43015
6145377391
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 6 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Cameron
Lucian
Rink
PhD, MBA
Director of Research (Surgery)
Chief Science Officer
0
150
Common
1.5%
1.5%
OFFICER
1.5% of capital required for business. Lab management, protocols and grants.
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
408 Tipperary Loop
Delaware
OH
43015
6142022861
No response provided by applicant
39
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 7 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Emily
Elizabeth
Davies
PharmD
Pharmacist
Chief Compliance Officer
0
0
N/A
0
0%
OFFICER
Consulting
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-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
2765 Hampshire Road Apt. 103
Cleveland Heights
OH
44106
3306181052
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 8 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Jennifer
Marie
Klag
No response provided by applicant
Pharmacist
Chief Dispensary Officer
0
0
N/A
0%
0%
OFFICER
Consulting
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
488 Sherwood Dr.
Bay Village
OH
44140
2163150086
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 9 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Gary
Lee
Rockefeller
No response provided by applicant
Law Enforcement
Director of Security
0
0
N/A
0%
0%
OFFICER
Security and consulting.
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
11829 Julie Drive NW
Baltimore
OH
43105
6149897702
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 10 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Britton
Delaney
Rink
No response provided by applicant
Physician
Medical Advisory Committee
0
0
N/A
0
0
OTHER
Consulting
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
7000 Olenatary River Road
Delaware
OH
43015
6145659304
No response provided by applicant
43
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 11 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Mona
Rani
Prasad
No response provided by applicant
Physician
Medical Advisory Committee
0
0
0
0%
0%
OTHER
Consulting
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-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
2612 Dorset Road
Columbus
OH
43221
6147381879
No response provided by applicant
17
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 12 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Stephen
Mark
Alfieri
No response provided by applicant
Private Investor
Board Member
0
1562
Common
15.62%
15.62%
BOARD MEMBER
15.62% of capital required for business. Direction.
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
923 Fifth Avenue
New York
NY
10021
6465103555
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 13 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Justin
Wyatt
Ehrlich
No response provided by applicant
Self-Employed - Real estate development and entrepreneur
Owner
0
1042
Common
10.42%
10.42%
OWNER
10.42% of capital required for business
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
62 Bethune Street
New York
NY
10014
2126862500
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 14 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Marc
Ryan
Ravner
No response provided by applicant
Self-employed - Real estate development and entrepreneur
Owner
0
1042
Common
10.42%
10.42%
OWNER
10.42% of capital required for business. Real estate development consulting.
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
77 White Street Apartment 6
New York
NY
10012
9177431553
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 15 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Bryan
Thomas
Weadock
No response provided by applicant
Private Investor
Owner
0
1562
Common
15.62%
15.62%
BOARD MEMBER
15.62% of capital required for business. Direction.
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
985 Fifth Avenue, Apartment #20A
New York
NY
10075
6462020194
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 16 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Benjamin
Hertzel
Shaoul
No response provided by applicant
Entrepreneur, Developer
Owner
0
1042
Common
10.42%
10.42%
OWNER
10.42% of capital required for business. Real estate development consulting.
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
129 Charles Street
New York
NY
10014
9177333199
No response provided by applicant
No response provided by applicant
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 17 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Zane
Matthew
Fry
No response provided by applicant
Real Estate
N/A
0
200
Common
2%
2%
OWNER
2% of capital required for business. Real estate.
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
1637 W. 3rd Avenue
Columbus
OH
43212
6142888759
No response provided by applicant
34
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 18 of 18
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Jay
No response provided by applicant
Karr
No response provided by applicant
Manager and Technology Consultant
Manager
0
N/A
N/A
N/A
N/A
OTHER
Expertise includes extensive experience managing teams. Provides technology leadership and
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax
consultation services with a focus on security and legal compliance.
This response has been entirely redacted
This response has been entirely redacted
1203 W. 3rd Street
Columbus
OH
43212
6144273558
No response provided by applicant
10
This response has been entirely redacted
Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percentownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Compliance(Compliance with Applicable Laws and Regulations)
B-1.1 By selecting “Yes”, the Applicant, as well as all individually identified Prospective Associated KeyEmployees listed in this provisional license application, agree to comply with all applicable Ohio lawsand regulations relating to the operation of a medical marijuana dispensary.
B-1.2 By selecting “Yes”, the Applicant understands and attests that it must establish and maintain anescrow account or surety bond in the amount of $50,000 as a condition precedent to receiving amedical marijuana certificate of operation. OAC 3796:6-2-11
YES
YES
Compliance(Civil and Administrative Action)
B-2.1 Has the Applicant been the subject of an action resulting in sanctions, disciplinary actions or civilmonetary penalties or fines being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-2.2 Has the Applicant been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-2.3 Has criminal, civil, or administrative action been taken against the Applicant for obtaining aregistration, license, provisional license or other authorization to operate as a cultivator, processor, ordispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission offalse information?
B-2.4 Has criminal, civil or administrative action been taken against the Applicant under the laws ofOhio or any other state, the United States or a military, territorial or tribal authority, relating to any ofthe Applicant's Prospective Associated Key Employees' profession or occupation?
B-2.4.1 If "Yes" to any question in B-2, provide the following: Respondent / Defendant, Name of Caseand Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Nameand Address of the Administrative Agency Involved, and the Jurisdictional Court (Specify Federal,State and/or Local Jurisdictions)
NO
NO
NO
NO
N/A
Compliance(Prospective Associated Key Employee Compliance)
Item 1 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Alexius
James
Dorsey
OFFICER
Chief Executive Officer
The CEO is responsible for the overall success of the organization. He will work with the Board ofDirectors, to assure the Company's accomplishment of its mission and vision, along with theaccountability of the organization to its investors.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
N/A
NO
N/A
NO
N/A
NO
N/A
NO
N/A
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
N/A
NO
N/A
YES
NO
N/A
NO
N/A
NO
N/A
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
N/A
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 2 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Victor
Brandon
Dorsey
OFFICER
Chairman
The Chairman will provide guidance to the Board of Directors and manage the Board's business andactivities as a peer member. He will be accountable to the Board and act as a direct liaison betweenthe Board and the management of The Company through the CEO.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 3 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Syed
Saqib
Ali
OFFICER
Chief Medical Officer
The Chief Medical Officer will provide guidance for the direction of the organization from a medicalstandpoint; including the mission of medical marijuana education to health care providers and patients.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 4 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Joyce
Elaine
Griffith
OWNER
Chief Financial Officer
The Chief Financial Officer is responsible for the administrative, financial, and risk managementoperations of the company. Duties include the development of a financial and operational strategy andthe ongoing development and monitoring of control systems designed to preserve company assets andreport accurate financial results.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 5 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Jatin
Rajendra
Patel
OFFICER
Chief Operations Officer
The COO will be responsible for the company's day-to-day operating activities, including revenue andsales growth; expense, cost, and margin control; and monthly, quarterly, and annual financial goalmanagement. They will report to the CEO.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 6 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Cameron
Lucian
Rink
OFFICER
Chief Science Officer
The primary duties include establishing the company's strategic R&D portfolio and providing scientificinput in product development that is aligned with corporate strategy set forth by the CEO and Board ofDirectors.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 7 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Emily
Elizabeth
Davies
OFFICER
Chief Compliance Officer
Primary duties will include establishing standards and implementing protocols to ensure that thecompliance programs throughout the organization are effective in identifying, preventing, detecting andcorrecting noncompliance with applicable rules and regulations.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 8 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Jennifer
Marie
Klang
BOARD MEMBER
Chief Dispensary Officer
The CDO is responsible for finalizing organizational structure to support growth, optimizing day-to-dayoperations for continuous improvements to processes and procedures for improving efficiency andeffectiveness. They will also recruit top talent and oversee the development of new hires.
NO
No response provided by applicant
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 9 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
Gary
Lee
Rockefeller
OFFICER
Director of Security
The Director of Security ensures the safety and well-being of the facility, employees and transport ofmedical marijuana. He is responsible for managing contracts with the security system hardware andsoftware vendors, the alarm system, and any associated services providers. He reports to the COOand will serve as the main point of contact for state and local law enforcement, along with otherrelevant governmental agencies.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 10 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Britton
Delaney
Rink
BOARD MEMBER
Medical Advisory Committee
The role of the Medical Advisory Committee (MAC) is to guide strategy and set policy related toresearch activities, education efforts, and health issues around product development.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 11 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Mona
Rani
Prasad
BOARD MEMBER
Medical Advisory Committee
The role of the Medical Advisory Committee (MAC) is to guide strategy and set policy related toresearch activities, education efforts, and health issues around product development.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 12 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Stephen
Mark
Alfieri
OWNER
Owner
Provides, as a consultant, in-depth review and analysis into procedures and strategies to ensure thatthe business is successful.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 13 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Justin
Wyatt
Ehrlich
OWNER
Owner
Responsible for handling the company's overall operations and asset management, as well asmanaging the firm's real estate investment and finance activities.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 14 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Marc
Ryan
Ravner
OWNER
Owner
Owner
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
YES
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 15 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Zane
Matthew
Fry
OWNER
Owner
Involved in making decisions regarding APPLICANT’s overall operations and asset management.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 16 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Bryan
Thomas
Weadock
OWNER
Owner
Involved in making decisions regarding APPLICANT’s overall operations and asset management.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 17 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Benjamin
Hertzel
Shaoul
OWNER
Owner
Involved in making decisions regarding APPLICANT’s overall operations and asset management.
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
YES
Agri-Med Enterprises, Inc, 6660 Doubletree Ave, Suite 8, Columbus, OH 43229
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 18 of 18
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Jay
No response provided by applicant
Karr
OTHER
Manager
Oversee the operations of the dispensary, including managing staff, inventory, security andcompliance.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
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Business Plan(Property Title, Lease, or Option to Acquire Property Location)
C-1.1 Attach one of the following: Evidence of the Applicant’s clear legal title to or option to purchase the proposed site and facility.A fully-executed copy of the Applicant’s unexpired lease for the proposed site and facility and awritten statement from the property owner that the Applicant may operate a medical marijuanaorganization on the proposed site for, at a minimum, the term of the initial provisional license.Other evidence that shows that the Applicant has a location to operate its medical marijuanaorganization.
Uploaded Document Name: C-1.1_1420 E 5th Ave Purchase Agreement.pdfNOTE: This applicant uploaded document is the next 9 page(s) of this document.
C-1.2 Business Name, as it appears on the Applicant’s certificate of incorporation, charter, bylaws,partnership agreement or other official documents.
C-1.3 Trade names and DBA (doing business as) names
C-1.4 Business Address
C-1.5 City
C-1.6 State
C-1.7 Zip Code
C-1.8 Phone
C-1.9 Email
Agri-Med Enterprises, Inc.
No response provided by applicant
1420 E 5th Avenue
Columbus
OH
43229
8332474633
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Business Plan(Site and Facility Plan)
C-2.1 Applicants must show that they can expeditiously use a site and facility to meet the activitiesdescribed in the provisional license by attaching one of the following:
If the facility is in existence at the time that the provisional license application is submitted, submitplans and specifications drawn to scale for the interior of the facility.If the facility is in existence at the time that the provisional license application is submitted, and theApplicant plans to make alterations to the facility, submit renovation plans and specifications for theinterior and exterior of the facility.If the facility does not exist at the time that the provisional license application is submitted, submit aplot plan that shows the proposed location of the facility and an architectural drawing of the facility,including a detailed drawing, to scale, of the interior of the facility.
Uploaded Document Name: C 2.1_5th Ave Plot Plan.pdfNOTE: This applicant uploaded document is the next 3 page(s) of this document.
MARK DATE DESCRIPTION
SHEET TITLE
CONSULTANTS
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JANJIC ARCHITECTURE7317 Mt. Meeker RdLongmont, CO 80503
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0 4' 8' 12'SCALE: 3/16" = 1'-0"1 SOUTH ELEVATION0 4' 8' 12'SCALE: 3/16" = 1'-0"2 WEST ELEVATION
0 4' 8' 12'SCALE: 3/16" = 1'-0"3 EAST ELEVATION0 4' 8' 12'SCALE: 3/16" = 1'-0"4 NORTH ELEVATION
C-2.2 The Applicant also must submit evidence that it is in compliance with any local ordinances, rules,or regulations adopted by the locality in which the Applicant's property is located, which are in effect atthe time of the application. Include copies of any required local registration, license or permit. If norelevant zoning restrictions have been enacted, provide a professionally prepared survey whichdemonstrates that the Applicant is not in violation of restrictions pertaining to prohibited facilities and isnot located within 500 feet of a community addiction services provider as defined under section5119.01 of the Revised Code. OAC 3796:5-5-01 Uploaded Document Name: C-2.2_1420 E 5th Ave_Notice of Proper Zoning.pdfNOTE: This applicant uploaded document is the next 2 page(s) of this document.
C-2.3 Provide a location map of the area surrounding the proposed facility that establishes the facilityis at least 500 feet from a prohibited facility or a community addiction services provider as definedunder section 5119.01 of the Revised Code. In establishing the distance between a proposeddispensary and such a facility, the distance shall be measured linearly and shall be the shortestdistance between the closest point of the property lines of the proposed dispensary and the prohibitedfacility or community addiction services provider. The map must be clearly legible and labeled and maybe divided into 8.5*11 inch sections. OAC 3796:5-5-01 Uploaded Document Name: C-2.3_FifthAve_500 ft Survey.PDFNOTE: This applicant uploaded document is the next 1 page(s) of this document.
1.2.3.4.5.6.
Business Plan(Business Startup Plan)
C-3.1 A business startup plan is required for all dispensary provisional license applications. Thebusiness startup plan must provide a comprehensive set of activities necessary for the startup of thefacility within six months of receiving a provisional license. Provide a timeline describing the process,methods, or steps used to execute a compliant business startup plan that includes, at a minimum:
Security and surveillanceEmployee qualifications and trainingStorage of medical marijuana productsInventory managementRecord-keepingPrevention of medical marijuana diversion
OverviewAPPLICANT is unique in that we leverage the experience of an interdisciplinary team consisting ofboard certified pain physicians, an addictionologist, and pharmacists with managerial and researchexperience. We recognize the opiate epidemic plaguing Ohio and our goal is to promote a safe andreasonable alternative for patients with approved conditions. We seek to develop an approach thatbalances patient safety with efficacy of the products.
Security and SurveillanceAPPLICANT’S Director of Security (DOS) has worked in law enforcement since 1976 has extensiveexperience in creating and implementing security services and risk mitigation strategies in an industrialsetting. He will lead the process of developing and enacting the security and surveillance system at thedispensary.Initiated in June 2017, APPLICANT’S DOS, in cooperation with other retained security experts, begandesigning APPLICANT’S security protocol. A copy of the security overlay designed for the facility andthe specifications and images of the security/surveillance equipment will be provided to the Board ofPharmacy (Board) in its application.Within 14 days of provisional licensure, APPLICANT will retain a third-party consultant, approved bythe Board, to begin the implementation of its security plan. Within 20 days of a provisional licensure,APPLICANT will begin implementing physical, administrative, and technical measures to ensurecompliance with Ohio Administrative Code (OAC) §3796:6-3-16, including, but not limited to,construction to limit access to the dispensary department, a state-of-the-art surveillance system withclear lines of sight to all areas of the facility, and installation of a panic button, duress alarm, holdupalarm, motion detectors, and glass break detectors.Within 90 days of provisional licensure, APPLICANT will install its perimeter motion sensor detector,begin implementing signage mandated by the OAC §3796:6-316, create internal barriers separatingthe dispensary from other areas of the facility, build a vault to store medical marijuana and records,and all other steps needed to comply with OAC §3796:6.APPLICANT anticipates all construction and security protocols to be completed within 120 days ofprovisional licensure.Employee QualificationsAPPLICANT’S Chief Executive Officer (CEO) in cooperation with the Chief Operating Officer (COO)will have the responsibility of developing and sourcing a human resources department to overseemuch of its internal employment practices. With over 4 decades of organizational leadership andoperations experience, including the hiring and vetting of hundreds of employees, both will play asignificant role in ensuring APPLICANT will hire experienced and qualified dispensary key employeesand support employees actively licensed by the Board pursuant to OAC §3796:6-2-07 and OAC§3796:6-2-09. No unlicensed staff will be employed by APPLICANT.Thirty (30) days prior to provisional licensure, APPLICANT will identify prospective Key Employees
who are licensed or will become licensed by the Board in accordance with OAC §3796:6-2-07 prior tothe commencement of APPLICANT’S operations. APPLICANT will contract with ASG Investigations toperform background checks on prospective Key Employees prior to hiring. Prospective Key Employeesunable to meet the criminal background criteria established by the Board will be notified of theirdisqualification within three (3) business days.Within 90 days of approval of its provisional license, APPLICANT will begin vetting applicants to ensurecompliance with OAC §3796:6-2-09 (licensure of key employees and support employees).Employee TrainingAPPLICANT’S COO, along with the Chief Dispensary Officer and Designated Representative, will haveprimary responsibility of APPLICANT’S training regimen. At least sixty days prior to the dispensing ofmedical marijuana, APPLICANT will seek the Ohio State Board of Pharmacy's approval of all writtenand electronic materials to be used in the training and education of the APPLICANT’s employees.Separately, APPLICANT will provide the Board with a signed attestation from a pharmacist orprofessional qualified to prescribe medical marijuana pursuant §4729(I), attesting that the professionalis responsible for the training content relating to OAC §3796:6-3-19 (C)(3)(b), (C)(7), and (E)(1) to(E)(4), and approves of the content of the materials.Upon Board approval of the training materials, the APPLICANT will immediately begin hiring vettedmembers of the local community who are employees licensed by the Board as key employees andsupport employees.In-person training by the APPLICANT's Designated Representative and/or other third party medicalcannabis experts will commence no less than 15 days prior to APPLICANT's dispensing of medicalmarijuana.
Storage of Medical MarijuanaThe COO and DOS will retain primary responsibility of the creation and oversight of a medicalmarijuana storage room and any procedures related to the safe storage of the medical marijuana.Within 30 days subsequent of obtaining provisional licensure, APPLICANT will begin construction of arestricted area or areas accessible only by employees and other authorized individuals wheremarijuana will be securely stored. APPLICANT anticipates this process will take five months.Upon construction of the structural portions of the marijuana storage room, APPLICANT willimmediately contract with a certified third-party vendor to begin the implementation of a security andsurveillance system compliant with OAC §3796:6-3-16. At a minimum, within 30 days prior tooperations, APPLICANT will have installed within the storage room security cameras, motion detectors,a duress alarm, a silent security alarm, a panic alarm, a holdup alarm, and an automatic voice dialer.To ensure access to the medical marijuana storage room is limited to authorized individuals,APPLICANT will install physical access control systems. These will include electronic and manuallocks at all access points to the room including doors and windows.APPLICANT will begin and maintain construction of the various components needed to light, ventilate,moderate temperature and humidity, and safely store the medical marijuana throughout the entirety ofthe construction process.Inventory ManagementWithin ten (10) days of provisional licensure, APPLICANT will contract with an approved third-partyvendor to implement its Inventory Management System.APPLICANT anticipates software installation within 45 days of operations and that it will take between5-15 days to receive the hardware and software required to implement the Inventory ManagementSystem. Within 10 days of receiving the software, APPLICANT will begin training its employees on theuse of the software. APPLICANT anticipates the training will last 3 days.Immediately after contracting with the software company, APPLICANT will register with The AmericanSociety for Automation in Pharmacy to ensure all data collected and submitted to the PrescriptionMonitoring Program Clearinghouse is available in the Ohio Automated Rx Reporting System (OARRS).APPLICANT anticipates this process will take between 30-45 days.
1.2.3.4.5.6.
C-3.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in C-3.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
C-3.2 The Business Startup Plan also must describe how the Applicant’s proposed businessoperations will comply with statutory and regulatory requirements (as described in Chapter 3796 of theRevised Code and division 3796:6 of the Administrative Code) necessary for the startup and continuedoperation of the facility including, but not limited to:
Security and surveillanceEmployee qualifications and trainingStorage of medical marijuana productsInventory managementRecord-keepingPrevention of medical marijuana diversion
APPLICANT will not dispense medical marijuana until it has fully integrated the BioTrackTHC softwareinto its operations, trained all employees on the usage of the software, and integrated its systems in amanner that allows for prompt and accurate reporting to the Board.Record KeepingAPPLICANT will use approved software to document all events and transactions in compliance withOAC §3796. Prior to provisional licensure, APPLICANT will have established policies and proceduresmeeting the record keeping requirements of OAC §3796:6-3-17. At least 30 days prior to thedispensing of medical marijuana, all dispensary key employees will receive in person training directlyfrom the vendor or other qualified third party on the usage and maintenance of the hardware andsoftware. Prior to dispensing medical marijuana, all dispensary employees will receive a minimum of 3hours of training related to OAC §3796-3-17 recordkeeping requirements and between 1-3 days ofhands-on training of all record maintenance software.Prevention of Medical Marijuana Diversion:Within 120 days of provisional licensure, APPLICANT will ensure that its anti-diversion programcomplies with Ohio Administrative Code (OAC) §3796:6-3-01(L), §3796:6-3-05(D)(7), §3796:6-3-08(B),§3796:6-3-16(B)(15), §3796:6-3-16(I), §3796:6-3-16(H), §3796:6-3-17(C)(4).Prior to Provisional Licensure:1. APPLICANT has hired a DOS and retained security consultants to design a security protocol toeliminate/mitigate the risks of medical marijuana diversion through administrative, technical, andphysical safeguards.2. APPLICANT has retained an architectural firm with extensive experience in the design of marijuanadispensaries. The firm has designed a dispensary that prioritizes security and anti-diversion.Within 10 days of provisional licensure: APPLICANT will contract with an approved vendor to trackmedicinal marijuana from receipt to dispensing, including to track all instances of recalls anddestruction of medical marijuana.Within 10 days of provisional licensure (Construction Phase): APPLICANT will begindemolition/construction of the dispensary. Prior to demolition, APPLICANT will have all constructionplans approved by the relevant local authorities and have agreed to terms with its contractors.APPLICANT will ensure that all construction plans include the anti-diversion protocols explained in theresponse to D-7.1.Within 30 days of provisional licensure: APPLICANT will begin conducting background checks onprospective key and support employees in accordance with OAC §3796:6-3-07 and §3796:6-3-07.Beyond 20 days of provisional licensure and prior to Dispensing Medical Marijuana: APPLICANT willprovide all employees with the anti-diversion training, as noted in the response to D-7.1.
No response provided by applicant
Security and Diversion Prevention:APPLICANT’S Chief Compliance Officer (CCO), Director of Security (DOS), and DesignatedRepresentative (DR) will engage in a collaborative effort internally and with retained experts to developa comprehensive security and surveillance plan.APPLICANT’S DOS has been a part of the law enforcement community since 1976. DOS is an expertin the creation and implementation of security plans to guard both hard and soft targets from threats.DOS has been selected by APPLICANT to lead the security protocols specifically due to DOS’sexperience and success. DOS has led teams in cooperation with the United States Secret Service toimplement detailed security plans to protect foreign dignitaries and to detect and prevent incidents athigh profile events, including at 100,000-person venues. DOS also has extensive experience inemergency planning response to incidents of threats and violence which dovetails completely into theregulations and objectives of the Ohio Medical Marijuana Control Program.Using administrative, technological, and physical safeguards, APPLICANT will mitigate the risk ofinternal and external threats to stored medical marijuana, patients, caregivers, employees, andproperty.APPLICANT will use alarm, surveillance, and perimeter security equipment pursuant to OAC §3796:6-3-16. DOS will oversee installation of intrusion, duress, panic, and hold-up alarms; automatic voicedialer; motion and glass break detectors, and door/window sensors. Surveillance cameras will beinstalled at critical points such as entry/egress points, storage safe, and near point of sale systems.APPLICANT will also partner with local community and law enforcement for external reporting ofsuspicious activity. APPLICANT will proactively reach out to the local community on a regular basis toeducate and reassure that all safety and security protocols exceed the minimum requirementsestablished by Ohio.Using Crime Prevention through Environmental Design (CPTED), APPLICANT’S retained architect hascreated an external landscape that promotes open areas to reveal intruders and restrict areas wherethey can hide around common pedestrian areas or structure.
Vulnerable areas like the parking lot and the dumpster area will be well lit to allow for facialidentification from at least 30 ft. away. To promote a deterrent effect, security staff will remain visiblearound building exterior at all times that the dispensary is open.
Authorized visitors logged, surveilled, escorted, and restricted to designated areas: security commandcenter, transportation, storage and inventory, any area with medical marijuana products/components(OAC §3796:6-3-23).Employee Qualifications and Training:APPLICANT’S executive team and Medical Advisory Committee will work in cooperation to create anindustry leading education and training plan. APPLICANT’S Chief Compliance Officer (CCO), apalliative medicine clinical pharmacist, will lead the team in ensuring that all education and trainingrequirements are exceeded. CSO maintains the prerequisites to educate and train employees in thehighly regulated marijuana industry as the CSO’s experience is derived from a surgery center, which issaddled with rigid regulatory practices.APPLICANT’S Chief Dispensary Officer (CDO), Chief Operating Officer (COO), and DR will co-developemployee qualification and training programs; and in turn disseminate knowledge to those who retainprimary responsibility for the hiring and training of licensed dispensary key employees and dispensarysupport employees. APPLICANT will not hire any unlicensed individuals and will immediately terminateall employees that fail to maintain licensure.APPLICANT’S employees will be trained in accordance with the provisions of OAC §3796:6-3-19.Specifically, all employees will exceed the mandatory foundational training prior to dispensing medicalmarijuana and will be required to submit to at least 16 hours of ongoing training biennially.Employee training will be documented on a secure internal server for five (5) years.Storage of medical marijuana products:
Pursuant to OAC §3796:6-3-07(A)(1) and using procedures designed with the assistance of membersof the executive team, APPLICANT’S CDO will provide personal supervision of the medical marijuanaand related products, order forms, and all records relating to the dispensing of medical marijuana andrelated products. The CDO will receive at least three (3) hours of training per year related to physical,administrative, and technical safeguards related to the safe storage of medical marijuana.Access to areas where medical marijuana is stored will be limited to licensed employees, registeredpatients/caregivers (excluding the storage vault), and other individuals whose responsibilities requireaccess to the medical marijuana (i.e., authorized Board agents or law enforcement). The entrance tothe secure room will comply with commercial security standards, be equipped with cipher or chip-activated keyed lock or equivalent, and not be visible from public areas of the premises. Theconstruction of the vault will meet or exceed FEMA 320, 361 and ICC-500 recommendations.Written log of all employees with storage room access will be updated daily.Record Maintenance:Upon Board approval, APPLICANT will use an approved vendor to document all events andtransactions (OAC §3796:6-3-07), plus maintain electronic tracking system to record all staffentering/exiting restricted access for five (5) years. System will ensure adequate security, Board-accessibility, prevent erasures/unauthorized data changes, and irregularities of reconstruction (OAC§3796:6-3-17(C)).Climate Control and Lighting:Pursuant to 3796:6-3-06, areas where medical marijuana and devices are stored will be dry, well-lit,ventilated, and clean. Temperature and humidity levels will be maintained at optimal levels for medicalmarijuana products.Heating, cooling, and humidity will be controlled in the storage room.LED lighting with sensors linked to automated controls and emergency battery-powered lighting will beutilized, in case of power failure, allowing for safety, security, continued business, recordkeeping, andworkflow. Low LUX video cameras will be employed to capture activity under low light conditions.Dispensary agents will inspect lighting daily and address discrepancies.Sanitation of Storage Areas:Dispensary agents will sanitize fixtures and equipment to prevent contamination (U.S. FDARegulations, CFR, Title 21, Sec. 211.67, GMP for Finished Pharmaceuticals).Written cleaning and maintenance procedures will be created setting a roadmap for policy measuresallowing for a contaminate free storage area without altering safety, identity, strength, or protectionfrom contamination prior to use.Procedures:• Schedule responsibility for cleaning, sanitizing, and maintaining equipment• describe methods, equipment, and materials used in cleaning/maintenance operations• disassemble/reassemble equipment if needed• remove/obliterate previous batch identification before processing next batch• protect clean equipment from contamination• inspect cleanliness before use
Business Plan(Description of Employee Duties and Roles)
C-4.1 Please provide a description of the duties, responsibilities, and roles of each ProspectiveAssociated Key Employee. Please attach a Table of Organization and Control for the business. Include all individuals listed in question A-6. Person 1 will serve as CEO and be responsible for the overall success of the organization. He will workwith the Board of Directors, to assure The Company’s accomplishment of its mission and vision, alongwith the accountability of the organization to its investors.Person 2 will serve as Chairman to provide guidance to the Board of Directors and manage theBoard's business and activities as a peer member. He will be accountable to the Board and act as adirect liaison between the Board and the management of The Company through the CEO. Hisexperience as a pain physician will direct the overall strategic vision for The Company.Person 3 will serve as Chief Medical Officer to provide guidance for the direction of the organizationfrom a medical standpoint. This will include educating health care providers and patients about medicalmarijuana. His experience as a pain physician and clinical teaching professor makes him an idealcandidate.Person 4 will serve as the Chief Financial Officer. She will be responsible for the administrative,financial, and risk management operations for the company. She will use 20 years of experience inbanking and lending to oversee the development of a financial and operational strategy, as well as theongoing development and monitoring of control systems designed to preserve company assets andreport accurate financial results.Person 5 will serve as Chief Operations Officer and report to the CEO. The COO will use his 20 yearsin finance and asset management to be responsible for the company's day-to-day operating activities.This will include monitoring core business metrics as well as developing monthly, quarterly, and annualfinancial goals.Person 6 will serve as Chief Science Officer. The primary duties will include leveraging his previousexperience in phytochemical research to establish the company's strategic R&D portfolio and providescientific input in product development that is aligned with the corporate strategy set forth by the CEOand Board of Directors.Person 7 will serve as Chief Compliance Officer. Primary duties will include establishing standards andimplementing protocols to ensure that the compliance programs throughout the organization areeffective in identifying, preventing, detecting and correcting noncompliance with applicable rules andregulations.Person 8 will serve as Chief Dispensary Officer. She has extensive experience as a District PharmacySupervisor. She will be responsible for finalizing organizational structure to support growth, optimizingday-to-day operations for continuous improvements to processes and procedures for improvingefficiency and effectiveness. She will also recruit top talent and oversee the development of new hires.Person 9 will serve as Director of Security, whose primary responsibility is to ensure the safety andwell-being of the facility, employees and transport of medical marijuana. He will use his 28 years of lawenforcement experience to manage contracts with the security system hardware and software vendors,the alarm system, and any associated service providers. He reports to the COO and will use hisprevious experience coordinating with agencies such as the SWAT team and Secret Service to serveas the main point of contact for state and local law enforcement, along with other relevantgovernmental agencies.Person 10 and Person 11 will use their expertise as physicians to serve on the Medical AdvisoryCommittee. Their role is to guide strategy and set policy related to research activities, educationefforts, and health issues around product development. Both are involved in various medicinecommittees, and Dr. Prasad is a recognized addiction expert.Person 12 is an Owner who provides, as a consultant, in-depth review and analysis into proceduresand strategies to ensure that the business is successful.
C-4.2 Please attach a Table of Organization and Control for the business. Include all individuals listedin question A-6.
Person 13 is also an owner and will be responsible for handling the company's overall operations andasset management, as well as managing the firm's real estate investment and finance activities.Person 14 is an owner. He has a record of optimizing revenue in real estate and businessdevelopment.Person 15 is an owner with a background in real estate development who maintains a large portfolio ofcash flow assets. He will also be involved in making decisions regarding APPLICANT’s overalloperations and asset management.Person 16 is an owner who will use his wealth of experience in operations, global market leadership,analytics to help develop company strategy.Person 17 is an owner who will use his 10 years in commercial real-estate brokerage to make informedfinancial decisions conducive to APPLICANT’s future.Person 18 is a Designated Representative and will apply his technology, marketing and vision to theAPPLICANT. Experience includes digital strategy for mental health practitioners, balancing security,legal and business.
Uploaded Document Name: C 4.2 Org Chart.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
AGRI-MED ORGANIZATIONAL CHART
CEO -Alexius James Dorsey
Chief Financial Officer - Joyce Elaine Griffith
Chief Operations Officer - Jatin
Rajendra Patel
Chief Science Officer -
Cameron Rink
Chief Compliance
Officer - Emily Elizabeth Davies
Chief Dispensary Officer - Jennifer
Klag
Designated Represenatative
Director of Security - Gary Lee Rockefeller
Advisors
Britton RInk
Mona Rani Prasad
Chief Medical Officer - Syed
Saqib Ali
Owners
Stephen Mark Aflieri
Justin Wyatt Ehlrich Benjamin Shaoul Bryan Thomas
Weadock Zane Mathew
Fry
Business Plan(Capital Requirements)
Item 1 of 1
C-5.1 Type of Capital
C-5.2 Source of Capital
C-5.3 Name and Address of financial institution
C-5.4 Account Number
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for thefirst year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3).The total amount of liquid assets must be no less than $250,000. Provide unredacted documentationfrom the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution tosupport the capital requirements. (ORC 3796:6-2-02)
Cash in bank
Owner contributions
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5_FINANCIAL PROOF ATTACHMENT_Redacted.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Business Plan(Business History and Experience)
Item 1 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Alexius
James
Dorsey
Owner
Windsor Construction
6660 Doubletree Ave. Suite 8 Columbus, OH 43229
YES
04/18/2007-Present
Business Plan(Business History and Experience)
Item 2 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Victor
Brandon
Thompson
Owner
Orthopedic One
170 Taylor Station Road, Columbus Ohio 43213
YES
2011-Present
Business Plan(Business History and Experience)
Item 3 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Syed
Saqib
Ali
Staff Physician Pain Medicine
Western Reserve Hospital
1900 23rd St, Cuyahoga Falls, OH 44223
NO
July 2010-Present
Business Plan(Business History and Experience)
Item 4 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Joyce
Elaine
Griffith
Chief Financial Officer
Columbus Title Agency of Westerville, Inc.
522 North State St., Westerville, OH 43082
YES
2003-2017
Business Plan(Business History and Experience)
Item 5 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Jatin
Rajendra
Patel
COO/CFO
Windsor Companies
6660 Doubletree Ave STE 8, Columbus, OH 43229
YES
2015-Present
Business Plan(Business History and Experience)
Item 6 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Cameron
Lucian
Rink
Director of Research (Surgery)
The Ohio State University Wexner Medical Center
410 W 10th Ave, Columbus, OH 43210
YES
2009-Present
Business Plan(Business History and Experience)
Item 7 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Emily
Elizabeth
Davies
Pain and Palliative Medicine Clinical Pharmacist, Department of Pain Management
San Antonio Military Medical Center
3551 Roger Brooke Dr., Fort Sam Houston, TX 78234
NO
August 2014 – 2017
Business Plan(Business History and Experience)
Item 8 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Jenniffer
Marie
Klag
Supervisor
CVS Health
1920 Enterprise, Parkway, Twinsburg, OH 44087
NO
2006-Present
Business Plan(Business History and Experience)
Item 9 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Gary
Lee
Rockefeller
K-9 Trainer
Stormdog Tactical
Sunbury, OH 43074, USA
YES
2012-Present
Business Plan(Business History and Experience)
Item 10 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Britton
Delaney
Rink
Director
Mount Carmel Health System
6001 East Broad St., Columbus, OH 43213
YES
2015-Present
Business Plan(Business History and Experience)
Item 11 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Mona
Rani
Prasad
Employee
Mount Carmel Health System
6001 East Broad St., Columbus, OH 43213
YES
2015-Present
Business Plan(Business History and Experience)
Item 12 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Stephen
Mark
Alfieri
Owner
Investor
923 Fifth Ave, New York, NY 10021
YES
2011-Present
Business Plan(Business History and Experience)
Item 13 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Justin
Wyatt
Ehrlich
Principal/Owner
VE Equities
250 Bowery Floor 2, New York, NY 10012
YES
2008-Present
Business Plan(Business History and Experience)
Item 14 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Marc
Ryan
Ravner
Principal/Owner
Magnum Real Estate Group
594 Broadway Ste., 1010 New York, NY 10012
YES
2000-Present
Business Plan(Business History and Experience)
Item 15 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Bryan
Thomas
Weadock
Managing Director, Senior Officer
Bank of America
One Bryant Park, New York, NY 10036
NO
2009-2016
Business Plan(Business History and Experience)
Item 16 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Benjamin
Hertzel
Shaoul
Principal/Owner
Magnum Real Estate Group
594 Broadway Ste., 1010 New York, NY 10012
YES
1997-Present
Business Plan(Business History and Experience)
Item 17 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Zane
Matthew
Fry
Director
Independent Contractor
1673 W. 3rd St., Columbus, OH, 43212
YES
2009-Present
Business Plan(Business History and Experience)
Item 18 of 18
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Jay
No response provided by applicant
Karr
VP, Director of Technology
inVentiv Health
500 Olde Worthington Rd., Westerville, OH 43082
YES
May 2015-June 2016
Business Plan(Business History and Experience Narrative)
C-6.9 Provide a narrative description not to exceed 1500 words demonstrating any previousexperience at operating other businesses or non-profit organizations and any demonstrated knowledgeor expertise with regard to the medical use of marijuana to treat qualifying conditions (for allProspective Associated Key Employees with an ownership interest of ten percent or more in theprospective dispensary). Include the number of years of experience, the type of business, and anyadministrative discipline history associated with each business. Person 1 (Chief Executive Officer)- owns and manages over 1000 residential units and 400,000 squarefeet of commercial space. He founded The Windsor Companies in 1999, a private diversifiedconstruction company operating in real estate investment, residential, commercial, retail and multi-family construction, development and property management sectors. It holds $100M in assets.
Person 2 MD (Chairman)- is a triple-board certified physician who completed his residency at The OhioState University, where he served as Chief Resident. He is a founding partner, owner, and boardmember of an Ambulatory Surgery Center, which grew from 20 physicians to 60+ providers. He is amember of several nationally recognized medical societies and has been nominated to serve onseveral committees at the national level.
Person 3 MD, MBA (Chief Medical Officer)- is a clinical faculty member at two academic medicalcenters and on the advisory board for Theravasc, a private pharmaceutical company developing non-opiate medication for neuropathic pain. He has assisted in growing a regional hospital and developingsafety protocols and treatment for pain patients. He has written two book chapters and been invited tolecture at national anesthesia and pain conferences. He is board-certified in Anesthesiology, PainMedicine, and Independent Medical Examination. He is board eligible in Functional Medicine.
Person 4 (Chief Financial Officer)- has over 20 years of experience in banking and lending, including10 as CFO for Columbus Title Agency, which services 50K transactions with a dollar volume of $100Mannually.
Person 5 (Chief Operations Officer)- has over 20 years of experience in finance and assetmanagement, including a global financial services firm. He serves as COO and CFO for a privatediversified construction company in commercial, residential, retail and multi-family construction, realestate investment, development and property management. He is an operations leader with strongfinancial expertise, building and optimizing organizational processes, measurement systems, andinfrastructure to maximize business results.
Person 6, PhD, MBA (Chief Science Officer)- has served as Director of Research for the Division ofVascular Diseases and Surgery at The Ohio State University (OSU) Wexner Medical Center since2009. He is a Principal Investigator and tenured Associate Professor with 15 years of experiencequantifying dietary phytochemical tissue distribution in living systems including human vital organs. Hislaboratory at OSU focuses on phytochemical interventions against neurological injury, and he has beenfunded by the American Heart Association, National Institutes of Health, and the U.S. Department ofDefense. He holds multiple patents on treating human disease with natural products and industry-sponsored research grants.
Person 7, PharmD, CPE (Chief Compliance Officer)- has served as the Pain and Palliative MedicineClinical Pharmacist at San Antonio Military Medical Center, serving active duty service members andveterans. Her clinic focused on weaning patients off opioid and benzodiazepine medications and hasimplemented the use of synthetic THC medication for pain control, PTSD, anxiety, muscle relaxation,
and inflammation. She currently serves as a Clinical Pharmacist of Rheumatology at UniversityHospital Home Health and has participated and directed research projects that have focused on usingan FDA approved synthetic formulation of THC in an off-label fashion for opioid weaning. She is amember of the American Society of Health-System Pharmacists and American Society of PainEducators. Dr. Davies earned her pharmacy doctorate from Ohio Northern University.
Person 8, PharmD (Chief Dispensary Officer)- has served as the District Pharmacy Supervisor for CVSHealth since April 2016, having spent the previous 5 years as a pharmacy manager. She oversees andmanages 19 stores in the Cleveland area and that Pharmacists in area of responsibility comply with allfederal, state and local laws as well as standards pertaining to the pharmacy. She providesprofessional, developmental and technical guidance and support to Pharmacists in addition tomanaging the company’s pharmacy marketing, quality control and inventory optimization programs.She ensures professional quality control standards are maintained through control of misfills(identifying and correcting the causes), optimization of process flow and communication of professionalpharmacy practices, as well as Rx inventory optimization by monitoring store inventories and sales. Dr.Klag earned her pharmacy doctorate from Ohio Northern University.
Person 9 (Director of Security)- graduated from the Ohio Peace Officers Training Academy in 1976 andserved as an auxiliary in the Reynoldsburg police department before moving to the Franklin CountySheriff’s Office in 1979, where he served on the Jail Operations Bureau, Patrol Bureau, and was amember of the original FCSO K9 Unit when it was founded in 1986. He has coordinated with theSWAT team for use of the k9s for multiple raids that were conducted and, every election year, with theSecret Service to provide sweeps for multiple dignitary visits to the Central Ohio Area. He wasSergeant of K9 Unit when he retired from Franklin County in 2007 and began working full-time as atrainer for Stormdog Tactical K9. In addition to explosive detection K9s, he has trained and handled anarcotic detection K9 who specialized in narcotic detection. He is a training instructor for severalfederal agencies.
Person 10 (Medical Advisory Committee)- is a physician and director of Maternal Fetal Medicine forMount Carmel Health. She completed a postgraduate fellowship program and served as Chair of theEthics Committee at The Ohio State University. She is dual-board certified and holds chair positions fornationally recognized medical committees.
Person 11 (Medical Advisory Committee)- is a physician and director of substance abuse treatmentand prevention program at The Ohio State University providing care to patients with concomitant opiateuse disorder. She is recognized as an addiction expert and leader in her field, retained by severalpatient care societies.
Person 12 (Owner)- is an entrepreneur, private investor, and consultant with 20 years of experience inbuilding new businesses. He co-founded and built Stanfield Capital Partners, LLC, which grew to $34Bin assets under management across three platforms.
Person 13 (Owner)- is a partner in VE Equities, LLC, a real estate company that offers investment,finance, asset management and construction. He manages investments and finance activities andhandles overall operations and asset management. He has completed over $5B of luxury mixed-useand condominium projects.
Person 14 (Owner)- has a record of optimizing revenue in real estate and business development. Hehelped grow a legacy family parking business beyond a $100M valuation and is on the leadership teamof Magnum Real Estate Group, one of the fastest growing residential real estate development andmanagement companies in New York City.
Person 15 (Owner)- is managing director and co-head of Global Fixed Income, Currencies andCommodities Sales for the Global Markets group at Bank of America Merrill Lynch. He is also amember of the Global Markets Leadership, Team and director of Merrill Lynch, Pierce, Fenner & Smith,a U.S.-registered broker-dealer. Prior to joining the firm in 2009 as head of Americas Fixed IncomeSales, Weadock spent 17 years at J.P. Morgan in a variety of roles, including head of Fixed Incomeand Currencies Sales for North America, and head of North American High Grade & Structured CreditSales. He previously spent 5 years as a fixed income and equity research sales analyst at Keefe,Bruyette & Woods, Inc., a New York investment bank. He served on the Board of Directors of theSecurities Industry and Financial Markets Association (SIFMA) from 2011-2014 and was a member ofthe Board's Executive Committee from 2012-2014. He also served on the Board of Directors of theGlobal Financial Markets Association (GFMA) from 2012-2014.Person 16 (Owner)- founded Magnum real estate development and acquisition firm in 1997. Hecurrently manages Magnum’s portfolio with an estimated value of $4 billion. He has overseen theacquisition and redevelopment of over 150 New York City value add and new construction andconversion assets, including residential development, small and large box retail, and institutionaldevelopment such as resident housing facilities and new construction for sale condos. He is alsoinvolved in numerous charitable organizations including Friends of Hudson River Park, Mount SinaiHealth Systems, NY Academy of Art, Urban Heroes, Human Service Council and The JewishCommunity Project.
Person 17 (Owner)- is a commercial real-estate broker for over ten years, his knowledge and diverseexperience as a Director of Investment Services. He has completed over $150 million in grosstransactions to date, and has gained a reputation for placing the needs of his clients first. A provenveteran of the commercial real-estate industry, his expertise covers all sectors of real estate, includingmultifamily, office, retail, industrial, and other special asset classes such as self-storage anddevelopment parcels.
Person 18 (Designated Representative)- is experienced in managing teams, strategy and delivery oftechnology solutions for over 15 years. He was on the executive management team that produced theequivalent of $29 million in annual revenue work. He was responsible for hiring, training andmanagement of 50 technology associates in four different regional offices. He also grew the team withover 30 new hires, raised the level of talent and improved quality of delivery during a period ofunprecedented and unprojected growth in digital work.
Operations Plan(Dispensary Oversight)
D-1.1 By selecting "Yes", the Applicant attests that it will appoint a designated representativeresponsible for the oversight, supervision and control of operations of the medical marijuanadispensary. When there is a change in the appointed designated representative, the Applicant willnotify the State Board of Pharmacy within 10 business days of appointment. OAC 3796:6-3-05 YES
1.2.3.4.5.6.7.8.
Operations Plan(Security and Surveillance )
D-2.1 By checking “Yes,” the Applicant attests that it is able to continuously maintain effective security,surveillance and accounting control measures to prevent diversion, abuse and other illegal conductregarding medical marijuana and medical marijuana products.
D-2.2 Please provide a summary of the Applicant's proposed security and surveillance equipment andmeasures that will be in place at the proposed facility and site. These measures should cover, but arenot limited to, the following:
General overview of the equipment, measures and procedures to be usedAlarm systemsSurveillance systemSurveillance storageRecording capabilityRecords retentionPremises accessibilityInspection/servicing/alteration protocols
Please reference OAC 3796:6-3-16 for more information.
D-2.2.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-2.2. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
YES
This response has been entirely redacted
Uploaded Document Name: D-2.2.1_Security Plan.pdfNOTE: This applicant uploaded document is the next 50 page(s) of this document.
*Battery life may vary depending on alarms per day and environmental conditions of the installation site.
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D-2.3 By selecting “Yes”, the Applicant attests that the answer provided in response to Question D-2.2is voluntarily submitted to the State Board of Pharmacy in expectation of protection from disclosure asprovided by section 149.433 of the Revised Code. YES
Operations Plan(Receiving of Product)
D-3.1 By selecting "Yes", the Applicant attests that it is able to safely and securely receive medicalmarijuana and medical marijuana products.
D-3.2 By selecting "Yes", the Applicant attests that it will implement standard operating procedures toinspect, prior to accepting any medical marijuana. Defective products must be rejected. Defectiveproducts include, but are not limited to the following: expired, damaged, deteriorated, misbranded oradulterated medical marijuana. OAC 3796:6-3-06; OAC 3796:8
D-3.3 Please describe the Applicant's processes, procedures, and controls regarding the inspection ofmedical marijuana from cultivators and processors prior to accepting any delivery at the proposeddispensary. Include a description of the proposed space for delivery and inspection. OAC 3796:6-3-06
YES
YES
.
D-3.3.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-3.3. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. No response provided by applicant
1.2.3.4.5.6.
Operations Plan(Storage of Product)
D-4.1 There will be separate, locked, limited access areas for the storage of medical marijuana that isexpired, damaged, deteriorated, mislabeled, contaminated, recalled, or whose containers or packaginghave been opened or breached, until the medical marijuana is returned to a cultivator, or processor,destroyed or otherwise disposed.
D-4.2 All storage areas will be maintained in a clean and orderly condition and free from infestation byinsects, rodents, birds, and pests.
D-4.3 A separate and secure area for temporary storage of medical marijuana that is awaiting disposalwill be established.
D-4.4 Please describe the Applicant's plans regarding the storage of medical marijuana within theproposed dispensary. The plan should include, but is not limited to, descriptions of the following:
Oversight of medical marijuana storagePhysical security measuresRecord maintenancePersons who will have access to medical marijuanaClimate control and lighting maintenance, including any necessary equipmentSanitation of storage areas
Please reference OAC 3796:6-3-07 for more information.
YES
YES
YES
The physical design and implementation of the practices related to APPLICANT’S storage of medicalmarijuana will be overseen by the Director of Security, a former law enforcement official with over 28years of experience in developing security plans. The Director of Security will work in cooperation withthe Chief Operating Officer (COO) and Chief Dispensary Officer (CDO), both with significantmanagerial and operations experience, to implement the plans related to access and security of storedmedical marijuana.Oversight of Medical Marijuana Storage:Pursuant to Ohio Administrative Code (“OAC”) §3796:6-3-07(A)(1) and using procedures designed withthe assistance of members of the executive team, APPLICANT’S Chief Dispensary Officer (CDO) willprovide personal supervision of the medical marijuana and related products, order forms, all recordsrelating to the dispensing of medical marijuana and related products. The CDO will receive at leastthree hours of training per year related to physical, administrative, and technical safeguards related tothe safe storage of medical marijuana.Physical Security Measures:
Record Maintenance:APPLICANT will maintain an electronic tracking system to keep a record of all staff entering/exitingeither room for minimum five years. Upon approval by the Ohio Board of Pharmacy to use anelectronic record management system and in accordance with OAC §3796:6-3-17(C), APPLICANT willensure that the electronic record management system has adequate security to guarantee theconfidentiality of the information contained within it, may be readily accessed by the State Board ofPharmacy, provides the most up-to-date technological features preventing erasures and unauthorizedchanges in data, and is capable of reconstruction.Access to Medical Marijuana:Only the following individuals will have access to areas containing medical marijuana (exclusive of thestorage room/vault): Employees licensed pursuant to §3796 who’s responsibilities require access tothe medical marijuana, registered patients or caregiver, other individuals whose responsibilitiesnecessitate a need to access the dispensary, including, but not limited to: 1. authorized agents fromthe State Board of Pharmacy and 2. law enforcement. Only Dispensary Key Employees and theDesignated Representative will have access to the vault storing the medical marijuana.Employees will not be permitted to access marijuana unless possessing a valid license pursuant to§3796 and only if the employees’ responsibilities necessitate access to the medical marijuana.Patients and caregivers must have registration validated prior to entering the dispensary department;however, they will not be allowed access behind any counters or other restricted areas within thedispensary.All other individuals, except for law enforcement and agents of the State Board of Pharmacy, willremain under the direct personal supervision of an APPLICANT employee while on the premises.Climate Control and Lighting:All areas where medical marijuana and devices are stored will be dry, well-lighted, well-ventilated, andmaintained in a clean and orderly condition. Storage areas will be maintained at temperatures andunder lighting conditions which will ensure the integrity of medical marijuana prior to being dispensed.APPLICANT will use a climate control system within the medical marijuana storage room that willmaintain optimal temperature, humidity, and lighting conditions to ensure the integrity of medicalmarijuana prior to its use.LED lighting will be placed throughout the medical marijuana storage room, as well as hallways anddoors leading to the storage room. In addition, emergency battery powered lighting will be installed incase of power failure. APPLICANT will use low LUX video cameras capable of capturing all activity inlow light conditions.Dispensary agents will inspect lighting daily, and any deficiencies will be reported to the DesignatedRepresentative or CDO. Secure room will contain sensors linked to our automated controls for lightingand CO2 and will work in tandem with other electronic monitoring of heat and humidity.Sanitation of Storage Areas:Dispensary agents will be responsible for sanitation of equipment contacting medical marijuana toprevent contamination in accordance with U.S. FDA Regulations, CFR, Title 21, Sec. 211.67 andCurrent GMP for Finished Pharmaceuticals.Equipment will be constructed such that surfaces in direct contact with medical marijuana are notreactive, additive, or absorptive. Substances required for operation of the dispensary will not touchmedical marijuana or medical marijuana products. Equipment and/or utensils will be cleaned,maintained, and sanitized to prevent malfunctions or contamination. Written procedures will befollowed for cleaning and maintenance of equipment and utensils used in packaging, labeling, orholding of medical marijuana.Procedures include:
D-4.4.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-4.4. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
• assignment of responsibility for cleaning, sanitizing, and maintaining equipment with schedules• description in detail of the methods, equipment, and materials used in cleaning and maintenanceoperations• methods of disassembling/reassembling equipment as necessary to assure proper cleaning andmaintenance• inspection of cleanliness immediately before use.
Uploaded Document Name: D-4.4.1_Security Plan.pdfNOTE: This applicant uploaded document is the next 50 page(s) of this document.
*Battery life may vary depending on alarms per day and environmental conditions of the installation site.
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Operations Plan(Dispensing of Product)
D-5.1 By selecting "Yes", the Applicant attests that it is prepared and willing to join the AmericanSociety for Automation in Pharmacy (ASAP) annually in order to facilitate near-real-time reporting tothe Ohio Automated Rx Reporting System (OARRS). American Society for Automation in Pharmacy; OAC 3796:6-3-08; OAC 3796:6-3-10
D-5.2 By selecting "Yes", the Applicant attests that it will use the patient registry to verify theregistration of a patient or caregiver. OAC 3796:6-3-08
D-5.3 Please indicate the expected number of Patient Registry scanners needed for the Applicant'sfacility (Information Only).
D-5.4 By selecting "Yes", the Applicant attests that it will have at least two employees physicallypresent at the dispensary location, one of whom is a dispensary key employee, when the dispensary isopen for the sale of medical marijuana. OAC 3796:6-3-03
D-5.5 Please describe the Applicant's processes, procedures, and controls regarding the dispensing ofmedical marijuana, updating the patient record, and product labeling. Describe how these will besupported by the Applicant's internal inventory system including integration with the state inventorytracking system and for reporting to OARRS using the current ASAP format. Please attach a sampleproduct label, with any identifiable information redacted or anonymized. OAC 3796:6-3-08; OAC3796:6-3-09; OAC 3796:6-3-10
YES
YES
5
YES
APPLICANT’s Chief Operating Officer (COO) and Chief Dispensary Officer (CDO) in cooperation withDesignated Representative, will implement and oversee all policies and procedures related todispensing of medical marijuana and transmission of all related information to the Ohio Board ofPharmacy (Board).APPLICANT’S COO brings experience in risk management, ensuring effective operational control, andcompliance. With over 20 years in the financial services and construction industries, COO hasdemonstrated an ability to create processes and controls to ensure the documentation and reporting ofsmall, but numerous transactions. COO’s work across multiple industries demonstrates the type ofadaptability that will allow seamless transition into the marijuana industry. COO also holds an MBAfrom one of the most respected institutions of higher learning in the world.Dispensing Process:COO, CDO, and Designated Representative will ensure that medical marijuana will only be dispensedin accordance with Ohio Administrative Code (OAC) §3796:6-3-08. At point of sale, a dispensaryemployee will be required to verify a registry identification card with another form of approved state-issued photographic identification belonging to a qualifying patient or caregiver, prior to selling medicalmarijuana to such qualifying patient or caregiver.A dispensary employee will record all relevant data pursuant to OAC §3796:6-3-08 through itsapproved vendor for reporting to OARRS within 5 minutes of dispensing medical marijuana.Updating Patient Record:Pursuant to Ohio Revised Code (ORC) §3796.08(B) of the Revised Code and ORC §4729.80(C),
patient-specific dispensary transactions are confidential and not a public record. A person havingaccess to such records will not divulge the contents thereof, or provide a copy thereof, to anyoneexcept:(1) The patient for whom the recommendation or medical marijuana order was issued or that patient'sdesignated caregiver;(2) The certified physician who issued the recommendation;(3) Certified and or licensed health care personnel who are responsible for the care of the patient;(4) A member, inspector, agent, or other investigator of the State Board of Pharmacy or any federal,state, county, or municipal officer whose duty is to enforce the laws of this state or the United Statesrelating to drugs and who is engaged in a specific investigation involving a designated person or drug;(5) A government agent.Pursuant to division ORC §3796.08 (A)(8)(c), in an emergency, the COO or DesignatedRepresentative may disclose the recommendation information when it is deemed to be in the bestinterest of the patient. A licensed employee making an oral disclosure in an emergency must prepare awritten statement with patient's name, date and time the disclosure was made, nature of theemergency, and names of the individuals by whom and to whom the information was disclosed. Allpatient-specific information related to dispensing of medical marijuana, including consents, writtenstatements of emergency disclosures, and written requests pursuant to paragraph ORC §3796.08(A)(8) of this rule, will be kept on file at the dispensary for at least three years in a readily retrievablemanner.
Each patient and/or caregiver will have a file in the patient record system with their name and patientidentification number. The file will contain all necessary medical information pertaining to the patientand their specific needs. If there is any change (i.e. in patient’s medical condition, insurance, etc.) it isthe responsibility of the patient and/or their caregiver to notify APPLICANT, at which point authorizeddispensary agents will access the patient’s record and document the necessary changes.
Prior to sale, APPLICANT will ensure certain information is clearly provided on the outside of eachcontainer or package containing medical marijuana, including:Business/trade name and license number of the cultivator that cultivated the marijuana;Name, address and permit number of the grower/processor;Employee ID number of employee preparing the package;Product identifier;Date and quantity dispensed, including net weight measured in ounces and grams or by volume, asappropriate;Name and registry number of patient and, if applicable, name of designated caregiver;Name, address and license number of dispensary;Cannabinoid profile and concentration levels and terpenoid profile as determined by the testinglaboratory;Warning that states: "This product may cause impairment and may be habit-forming;"Statement: "This product may be unlawful outside of the State of Ohio;" andDate of harvest.If the product is in a form other than plant material, the following information and notices will beincluded:Date of manufacture;Name and license number of processor that manufactured product;List of all ingredients and all major food allergens as identified in 21 USC 343;Warning that states: "Caution: When eaten or swallowed, the effects and impairment caused by thisdrug may be delayed”; andIf marijuana extract was added to the product, a disclosure of the type of extraction process and anysolvent, gas or other chemical used in the extraction process or any other compound added to the
D-5.5.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-5.5. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
extract.If a cultivator or processor created package contains the warnings, notifications, and informationmandated by OAC 3796:6-3-09, APPLICANT will include on the label any required information alsoincluded on the cultivator or processor-created package if that information is obscured by the affixedlabel.With all product dispensed, APPLICANT will provide accompanying material disclosing any pesticideapplied to the marijuana plants and growing medium during production and process and that containsthe following warnings:"Warning: This product may cause impairment and may be habit-forming. Smoking medical marijuanais not permitted in the State of Ohio.""There may be health risks associated with consumption of this product.""Should not be used by women who are pregnant or breastfeeding.""For use only by the person named on the label of the dispensed product. Keep out of reach ofchildren.""Marijuana can impair concentration, coordination and judgment. Do not operate a vehicle ormachinery under the influence of this drug."The toll-free telephone line established by the state board of pharmacy in accordance with section3796.17 of the Revised Code.APPLICANT will use non-italicized twelve-point font on all accompanying materials.APPLICANT will include the following printed statement on the receipt or in the bag or other similarpackaging in which dispensed medical marijuana is transferred from its dispensary to a patient orcaregiver: "If you have a concern that an error may have occurred in the dispensing of your medicalmarijuana, you may contact the State of Ohio Board of Pharmacy, using the contact information foundat medicalmarijuana.ohio.gov."Applicant will use an approved vendor software to track the flow of inventory from receipt todispensing. Upon provisional licensure, APPLICANT will begin the process of registering with TheAmerican Society for Automation in Pharmacy, which will in turn allow it to submit information to thePrescription Monitoring Clearinghouse so that information is readily available in the OARRS system.At point of sale, APPLICANT will collect and transmit information to the OARRS system in accordancewith OAC §3796:6-3-10(A)(1)-(23), which will be entered into the Approved vendor system and beconverted into a readable ASAP format.If APPLICANT does not sell medical marijuana for a 24-hour period or is closed for business, it willsubmit a “zero report,” or cause one to be submitted. In case of a malfunction of the Approved vendorsoftware, the Board will immediately contact the Board via telephone and in writing to document theincident. APPLICANT will immediately provide the Board with the information required by OAC§3796:6-3-10(A)(1)-(23) in writing.
No response provided by applicant
1.2.3.
Operations Plan(Inventory Management of Product)
D-6.1 By selecting "Yes" the Applicant attests that it will establish inventory controls and procedures forthe conducting of weekly inventory reviews and annual comprehensive inventories of medicalmarijuana at the facility. OAC 3796:6-3-20
D-6.2 By selecting "Yes" the Applicant attests that its written or electronic weekly and annual inventoryrecords described in D-6.1 will include:
The date of the inventoryA summary of the inventory findingsThe employee identification numbers, and titles or positions, of the individuals who conductedthe inventory
Please reference OAC 3796:6-3-20 for more information.
D-6.3 By selecting "Yes", the Applicant attests that it will use the state inventory tracking system. ORC3796.07; OAC 3796:1-1-01; OAC 3796:6-3-06
D-6.4 By selecting "Yes" the Applicant attests that it will maintain records of medical marijuanareceived from a cultivator or processor in its internal inventory control system. OAC 3796:6-3-20
D-6.5 By selecting "Yes" the Applicant attests that it will maintain records of medical marijuanadispensed to a patient or a caregiver in its internal inventory control system. OAC 3796:6-3-08
D-6.6 By selecting "Yes" the Applicant attests that it will maintain records of expired, damaged,deteriorated, misbranded, or adulterated medical marijuana awaiting return to a cultivator / processoror awaiting disposal, in its internal inventory control system. OAC 3796:6-3-20
D-6.7 Please provide an explanation for selecting "No" in response to questions D-6.1 through D-6.6
D-6.8 Please describe the Applicant's approach regarding the implementation of an inventorymanagement process. This approach must also include a process that provides for the recall ofmedical marijuana and the management of medical marijuana product returns from the proposeddispensary to the originating cultivator and/or processor. OAC 3796:6-3-20
YES
YES
YES
YES
YES
YES
No response provided by applicant
Pursuant to 3796:6-3-20 (A) and (B), APPLICANT’S Chief Dispensary Officer (CDO) will have primaryoversight of the dispensary's medical marijuana inventory control system. CDO will delegate certainresponsibilities to a Designated Representative (DR).APPLICANT will use an approved vendor to record all medical marijuana received, dispensed, sold,destroyed, or used. Approved vendor is a real-time, web based system that is backed up daily and will
be programmed to allow access to the Ohio Board of Pharmacy (Board) upon request.The Approved vendor will enable APPLICANT to collect, store, and retrieve all data and activity.Inventory records, patient records, recall reports, sales/transaction records, product disposal records,and all scanned documents can be accessed at any time, either in-system or through the reportcreation tool. Availability and reportability of system data will enable APPLICANT to produce anyinformation necessary for an inspection.Product in need of quarantine can be separated from bulk and placed in designated area. Inventorydestruction initiated through system will require documentation of destruction purpose and/or approvedmethod as well as employee performing action. Availability and reportability of the system data willenable APPLICANT to produce any information necessary for the Board during an inspection or uponrequest. Though system actions can be adjusted, at no time is any data ever fully deleted. Theapproved vendor’s software will log every action so an entire system history may be reconstructed.Pursuant to 3796:6-3-20 (G), all records of each day's beginning inventory, acquisitions, sales,disposal and ending inventory is kept for three (3) years onsite.The approved vendor software will log all information required by OAC §3796:6-3-20(C)(2)-(4) whenmedical marijuana is delivered, destroyed, sold, dispensed, or has sale denied.APPLICANT will also use other processes to ensure compliance with OAC §3796:6-3-20 and otherrelevant provisions of Code.Inventory Control to assure integrity of electronic manifest and Inventory Control SystemAPPLICANT will receive an electronic copy of a shipping manifest at least two (2) days prior toreceiving delivery and will be reviewed by its DR.When shipment arrives, utilizing segregation of duties, APPLICANT’S DR records products intoinventory who is not associated with creating the APPLICANT’S purchase order (PO). Segregation ofduties, reduces the chance of collusion. DR must sign off on accuracy of delivery invoice utilizing aprenumbered receiver, identifying SKU product numbers, and total inventory count received, andcompares amount received to APPLICANT’S PO for accuracy. If accurate, DR enters receipt ofinventory into the inventory management system. If not accurate, the shipment is rejected, or anyirregularity causing rejection is corrected before inventory is accepted.Pursuant to 3796:6-3-20 (D)(1), if APPLICANT designed internal control procedures (audits),conducted weekly, identifies undocumented reduction in inventory quantity, cause will be determined.Board will be notified and corrective action within two (2) business days, andPursuant to 3796:6-3-20 (D)(3), If audit identifies increase with no documented cause, cause will bedetermined, and corrective action will be taken.RecallAPPLICANT’S recall policy will be compliant with OAC §3796:6-3-21.Within 24 hours of initiating a recall, APPLICANT’s DR will contact the Board to notify it of its decisionto recall medical marijuana products due to a risk to public health and safety. If APPLICANT is directedto initiate a recall by the Board, the APPLICANT will begin its recall procedures immediately.In circumstances warranting a recall of medical marijuana or medical marijuana products,APPLICANT’S CDO or DR will immediately cease the sale and/or distribution of the impacted product.The DR will notify all staff members of the recall to ensure that the impacted product is not sold and willinstruct the dispensary staff to begin accepting any returns of the impacted product. The CDO willimmediately quarantine the impacted product and will examine all the other medical marijuanaproducts within its vicinity for signs of contamination, infestation, or other circumstances that may havealtered the condition of the medical marijuana.Once all the impacted medical marijuana identified, the CDO and/or DR will segregate the medicalmarijuana recalled within its secured storage room, using procedures designed by the Directory ofSecurity’s previous experience as a training instructor in narcotics detection and enforcement. Eitherthe Chief Dispensary Officer or the DR and at least one other dispensary agent will be present whensegregating the medical marijuana, ensuring marijuana is accurately accounted for.While maintaining strict compliance with state and federal health care privacy laws, APPLICANT’S DR
1.2.3.4.
D-6.8.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-6.8. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
D-6.9 Please describe the Applicant's processes, procedures and controls regarding a patient orcaregiver’s ability to return unused medical marijuana for the purpose of dispossession and destroying.Include, at a minimum, a description of
How patients and caregivers will be charged for such returnsHow returns will be trackedHow any returned medical marijuana will be secured at the facilityThe maximum amount of time that returned medical marijuana will be stored at the facility
will immediately begin contacting individuals who purchased or may have purchased the impactedproduct. The DR will primarily rely on telephone communications to warn impacted patients of a recall;however, if needed, the DR may contact impacted patients via personal visits, letters, or email.In instances where a significant number of patients are impacted or where the threat of harm topatients is severe, APPLICANT will use mass media to contact the general public of the recall, inconjunction with its attempts to contact those patients it has identified as purchasing the impactedproduct.APPLICANT will immediately notify originating cultivator and/or processor of any recall, but in no event,will the DR wait longer than four (4) hours of notice of the recall to initiate its contact. In cooperationwith the Board, the APPLICANT will arrange for the immediate removal from its dispensary of anyimpacted product and will continue to have the impacted product returned to the cultivator and/orprocessor on a rolling basis as the medical marijuana is returned. As stated above, the APPLICANTwill ensure that recalled medical marijuana is not intermixed with other products.
No response provided by applicant
Overview:Pursuant to Ohio Administrative Code (OAC) §3796:6-4-14(D) APPLICANT will not implement amedical marijuana buyback policy prior to receiving approval from the Ohio State Board of Pharmacy(Board).Charging:APPLICANT will not charge patients and/or caregivers (if applicable) for the return and destruction ofunused marijuana. If the medical marijuana was purchased at APPLICANT’S dispensary, APPLICANTwill reimburse patients for the pro-rata share of the unused medical marijuana returned if returnedwithin thirty (30) days of purchase. However, APPLICANT also reserves the right to reimburse patientsfor the full amount of the medical marijuana purchase, irrespective of the amount of medical marijuanareturned. Patients and/or caregivers will be refunded in the same form of payment used to make thepurchase (e.g. cash purchases will receive a cash refund, etc.).Destruction/Return of Medical Marijuana:At least seven (7) days prior to rendering medical marijuana unusable and disposing of it, APPLICANTwill notify the Board of its intent to destroy the product. APPLICANT will cooperate with the Board toestablish a recurring time and date which it will destroy returned medical marijuana to maintaincompliance with 3796:6-3-14(B).If a medical marijuana product is returned by a patient or caregiver, the Chief Dispensary Officer, theDesignated Representative, or his/her designee will examine the returned product to validate thereason for the return. If defects in the medical marijuana are found, any product that the dispensaryhas on hand from the same lot will be examined for a similar defect. The defective products will bepulled from inventory, quarantined, and destroyed by grinding and incorporating the marijuana wastewith other ground material so that the resulting mixture is at least 50 percent non-marijuana waste, in
D-6.9.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-6.9. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
accordance with OAC §3796:6-3-14. Marijuana-infused products will be destroyed and combined withat least 50 percent bleach in a disposal container to be rendered unusable before being delivered to apermitted solid waste facility for final disposition.Recordkeeping:APPLICANT will record the return of all medical marijuana in accordance with the recordkeepingrequirements of OAC §3796:6-3-17. APPLICANT will utilize an approved vendor to record the return ofany medical marijuana into the state inventory tracking system. Relevant information related to thereturn of the medical marijuana includes, but is not limited to: (1) a description of the products,including quantity, strain, variety, batch number and cause for the medical marijuana being destroyed;(2) the name and license number of the dispensary employee destroying the medical marijuana ormedical marijuana product; (3) the name and license number of the dispensary key employee verifyingthe destruction of the medical marijuana or medical marijuana product; (4) the method of disposal andthe name, address and telephone number of the disposal APPLICANT; (5) date of disposal; and (6)whether the return is the result of any adverse effects experienced by the patient. Despite theforegoing, APPLICANT will neither collect nor attempt to collect any information that may be contrary tostate or federal law.In accordance with OAC §3796:6(E)(1) and subject to Board approval, electronic records related to thedestruction of the medical marijuana will be stored in a secure, locked room for at least three (3) years.If the Board fails to approve of electronic record storage of the destruction of medical marijuana,APPLICANT will retain the records in a secure, locked room in hard-copy format for at least threeyears.In accordance with OAC §3796:6-3-14, APPLICANT will retain records related to the return of medicalmarijuana for at least three years. The records will also be entered into the state inventory trackingsystem.Secured Storage of Medical Marijuana:APPLICANT will segregate medical marijuana that is returned or recalled within its secured storageroom, using procedures designed by the Director of Security’s previous experience as a traininginstructor in narcotics detection and enforcement. Either the Chief Dispensary Officer or theDesignated Representative and at least one other dispensary agent will be present when segregatingthe medical marijuana, ensuring marijuana is accurately accounted for. Details of segregatedmarijuana will be entered into inventory control, including product batch or lot number, productdescription, weight of marijuana/amount of THC, recording time and date, licensed grower, andorigination. Returned medical marijuana will not be retained for longer than fourteen (14) days.APPLICANT will dispose of destructed marijuana waste in accordance with APPLICANT’S approvedwaste disposal plan. APPLICANT will maintain records of all destroyed products. Disposaldocumentation will include product description and type, quantity, date, time, location, reason fordisposal, and signed by two (2) dispensary agents. Records related to loss and/or destruction will bescanned and stored electronically, while hard copies will be kept in the operations zone.
No response provided by applicant
Operations Plan(Diversion Prevention of Product)
D-7.1 Please provide a summary of the procedures and controls that the Applicant will implement atthe dispensary for the prevention of the unlawful diversion of medical marijuana, along with the processthat will be followed when evidence of theft/diversion is identified. OAC 3796:6-3-01; OAC 3796:6-3-05; OAC 3796:6-3-16
,
1.2.3.4.
Operations Plan(Sanitation and Safety)
D-8.1 Please provide a summary of the intended sanitation and safety measures to be implemented atthe dispensary. These measures should include, but are not limited to, plans, procedures, and controlsto address the following:
Processes for contamination preventionPest protection proceduresInstruction to dispensary employees regarding the handling of medical marijuanaHand-washing facilities
Please reference OAC 3796:6-3-02 for more information. APPLICANT’S executive team and immediate advisors includes four physicians, two pharmacists, aChief Science Officer (CSO) responsible for creating and managing a hygiene plan, and othermembers with extensive experience in identifying and mitigating risk.APPLICANT’S Chief Compliance Officer (CCO) and CSO, in cooperation with the DesignatedRepresentative, will create and implement the sanitation and safety standards, policies, andprocedures for the dispensary. CCO, having been a part of the Editorial Board of a nationally publishedscience journal, possesses extensive expertise in the impacts of environmental contaminants and theirimpacts on human health, and steps that can be taken to mitigate these risks.Contamination Procedures:As set forth in Applicant’s Standard Operating Procedure, registered dispensary agents will maintainmedical cannabis free of contamination through a variety of means including: (1) wearing cleanclothing appropriate for the duties performed; (2) wearing protective apparel (such as a face mask)when necessary; (3) preventing bare-hand, direct contact with medical cannabis through the use ofgloves or sterilized tweezers; (4) washing hands with soap and warm water for a minimum of 20seconds after using the toilet, at the beginning and end of each shift, after coughing, sneezing, usingtissue or handkerchief, eating, drinking or using tobacco, after touching hair or any body part exceptclean hands and arms, after doing other activities that contaminate the hands, such as handling trashor cleaning chemicals, etc., (5) dispensing only medical cannabis that has been purchased from aState licensed grower or processor, which is known to be contaminate-free and lab-tested, (6) AlertingDesignated Representative of any open sores, wounds, or lesions or any other personal healthcondition, (7) maintaining and sanitizing all equipment at appropriate intervals to prevent malfunctionsor contamination that would alter the safety, identity, strength, quality or purity of the medical cannabis;(8) Utilizing work surfaces, that come in direct with contact medical cannabis, which are made ofsmooth impervious material (such as stainless steel), so that the work surfaces may be readily cleanedand sanitized; (9) General cleaning, such as dusting the furniture, fixtures, and artwork, daily sweeping/mopping/ vacuuming the floor, taking out the garbage, disinfecting phones, and scrubbing thebathroom and (10) Adhering to storage procedures to ensure adequate lighting, ventilation,temperature, humidity, space, and protection from unwanted elements.Pest Protection Procedures:General pest surveillance will be conducted daily by dispensary employees. Employees will be trainedto identify visual symptoms of pests, such as movement on plants, sighting rodent droppings, and thepresence of flying insects. In addition, employees will also take notice of any off colored leaves thatmay be indicative of disease, malfunctioning environmental controls, or deficient nutrients. Throughproper training, and hands-on experience, employees will learn to thoroughly inspect all parts of theplant, since pests hide in different places, including the undersides of pots, benches, leaves, stems,flowers, and all parts of the plant itself.If any indications of pest infestation exist, the Designated Representative shall immediately segregatethe infested medical marijuana in a sealed, air tight container. An immediate inspection of any adjacentmedical marijuana shall be made.Any medical marijuana that is segregated for purposes of destruction or return to a processor cultivator
shall be reported to the Board through it inventory tracking software. Unless otherwise directed by theBoard, infested medical marijuana shall be stored and disposed of in accordance with OAC §3796:6.Training:APPLICANT will incorporate quarterly reviews of procedures and practices to ensure that best quality,and safety practices are being implemented. Findings and results of these audits will be reviewed andimproved upon by Designated Representative using retained experts. The findings will also bedisseminated and used to design training and skill enhancement seminars, to be attended byemployees at every level.
Prior to dispensing marijuana, employees will receive at least two hours of hands-on training related torecognizing and addressing pest infestation. Employees will be required to complete 1 hour ofadditional training per year related to, at a minimum, signs of pest infestation.
Hand Washing:Employees will be required to wash their hands with soap and warm water for a minimum of 20seconds after using the toilet, at the beginning and end of each shift, after coughing, sneezing, usingtissue or handkerchief, eating, drinking or using tobacco, after touching hair or any body part exceptclean hands and arms, after doing other activities that contaminate the hands, such as handling trashor cleaning chemicals, etc.Employees will be required to wash their hands after handling any material suspected of beinginfested. If an employee or the Designated Representative suspects that an employee’s hair or articleof clothing may have become contaminated through the employee’s contact with suspected infestedmaterials, the employee will be required to change their clothes and/or wash their hair prior to returningto the dispensary.If a dispensary agent is out of work for more than three days, Designated Representative will require anote from a physician confirming the dispensary agent’s condition.Designated Representative will monitor the health of all dispensary agents, including their hygiene, toensure a sanitary work environment. In the event Designated Representative believes a dispensaryagent is ill, they will terminate the dispensary agent’s shift immediately. If upon dispensary agent’sreturn to work, Designated Representative still suspects the dispensary agent is ill, he or she willrequire the dispensary agent to obtain a physician’s release to return to work at the dispensary.In an effort to foster a healthy lifestyle for all employees, Applicant will institute a corporate wellnessprogram, which may include subsidizing local gym memberships, annual medical check-ups, andproper monitoring / treatment of any specific known health condition.
1.
2.3.4.5.6.7.
Operations Plan(Record-Keeping)
D-9.1 By selecting “Yes,” the Applicant attests that it will notify State Board of Pharmacy at least 7 daysprior to rendering medical marijuana unusable. All waste and unusable product will be weighed,recorded and entered into both its internal inventory system and in the state inventory tracking system.The destruction of medical marijuana will be witnessed by a key employee and conducted in adesignated area with fully functioning video surveillance. OAC 3796:6-3-14
D-9.2 Please provide a summary of the Applicant’s record-keeping plan at the dispensary. This planshould cover, but is not limited to, a description for how the following records will be maintained:
Employee records, including a background check conducted by the proposed dispensary andtraining provided by the proposed dispensaryOperating procedures and controlsAudit recordsStaffing plans; Business recordsSurveillance recordsAttendance logsQuality assurance review logs
Please reference OAC 3796:6-3-17 for more information.
YES
APPLICANT’S recordkeeping practices will be overseen by its Chief Dispensary Officer (CDO), ChiefOperating Officer (COO), and its Designated Representative (DR). APPLICANT may retain third partyexperts to ensure that all electronic data stored at the dispensary remains secure.Employee Records: APPLICANT will use an internal server to store all employee data. Data related toemployee background checks and training will be retained for a minimum of five (5) years and will beavailable for inspection/audit by the State Board of Pharmacy (SBP). All employee records will beentered into the electronic system by the DR within one business day of the individual coming inpossession of the document.
Operating Procedures and Controls:APPLICANT will retain all records electronically unless expressly prohibited by law, and will use asecure internal server to store all data related to its operating procedures and controls. The CDO willoversee all records relating to the dispensing of medical marijuana and medical marijuana products,unless the SBP has issued written approval to a dispensary allowing for the storage of records off-site.
APPLICANT will establish record keeping policies and procedures that exceed the requirements ofOAC §3796:6-3-17. At least 30 days prior to the dispensing of medical marijuana, all dispensary keyemployees will receive in-person training directly from the vendor or other qualified third party on theusage and maintenance of the hardware and software. In addition, all dispensary employees willreceive a minimum of three (3) hours of training related to OAC §3796-3-17, and between 1-3 days ofhands-on training of all record maintenance software.APPLICANT will maintain an electronic tracking system for a minimum of five (5) years to keep arecord of all staff entering/exiting controlled access areas, particularly the medical marijuana storageroom. Upon approval by the SBP to use an electronic record management system and in accordancewith OAC §3796:6-3-17(C), APPLICANT will ensure that the electronic record management systemhas adequate security to guarantee confidentiality.APPLICANT will use an approved vendor to record all medical marijuana received, dispensed, sold,destroyed, or used. The acts of dispensing and destroying of a controlled substance must bedocumented with the positive identification of the responsible individual. These records may be kept
electronically if the method is approved by the SBP and the records are backed-up each business day.
Audit Records:APPLICANT will retain all records electronically unless prohibited by law. APPLICANT will use asecured internal server to store all data related to its audit records. The DR will conduct and documentan audit of APPLICANT’S daily inventory according to generally accepted accounting principlesweekly. If the audit identifies a reduction in the amount of medical marijuana in APPLICANT’Sinventory not due to documented causes, the DR and the CDO will determine where the loss occurredand immediately take and document corrective action. APPLICANT will immediately inform the SBP ofthe loss by telephone and written notice of the loss and the corrective action taken within two businessdays after first discovery. If the reduction in the amount of medical marijuana in the inventory is due tocriminal or suspected criminal activity, the DR will immediately make a report identifying thecircumstances surrounding reduction to the SBP and law enforcement with jurisdiction where thesuspected criminal acts occurred.If the audit identifies an increase in the amount of medical marijuanain the APPLICANT's inventory not due to documented causes, the DR and/or the CDO will determinewhere the increase occurred and take and document corrective action.
Pursuant to 3796:6-3-20 (D)(4), APPLICANT will submit quarterly financial audit statements in a formatand medium approved by the SBP. Quarterly audits may include: an income statement, balance sheetand weekly medical marijuana inventory, including marijuana acquisition, wholesale cost and sales,prepared in accordance with generally accepted accounting principles. Annually, APPLICANT willsubmit an audit including the same information, compiled and certified by an auditor or certified publicaccountant in a format and medium approved by the SBP.
APPLICANT will maintain the documentation required of this rule in a secure, locked location for threeyears from the date on the document. These records may be kept electronically if the method isapproved by the SBP and the records are backed-up each business day.
Staffing Plans; Business Records:APPLICANT will retain all records electronically unless prohibited by law. APPLICANT will use asecure internal server to store all data related to staffing plans and business records not related toinventory and sales.Pursuant to 3796:6-3-20 (G), all records of each day's beginning inventory, acquisitions, sales,disposal and ending inventory will be kept for a period of three (3) years at the dispensary. IfAPPLICANT chooses to maintain such records at a location other than this place, APPLICANT will firstsend a written request to the SBP.Surveillance Records:APPLICANT will retain all records electronically unless prohibited by law. APPLICANT will use asecure internal server to store all data related to its surveillance records.APPLICANT will maintain twenty-four (24) hour recordings from all video cameras, which APPLICANTwill make available for immediate viewing by the Board or the Board’s authorized representative uponrequest. Records will be retained for at least five years. APPLICANT will provide the Board with anunaltered copy of such recording upon request. This copy will be time and date stamped. IfAPPLICANT is aware of a pending criminal, civil, or administrative investigation or legal proceeding forwhich a recording may contain relevant information, it will retain an unaltered copy of the recordinguntil the investigation or proceeding is closed or the entity conducting the investigation or proceedingnotifies the APPLICANT that it is not necessary to retain the recording.APPLICANT’S security equipment will be able to immediately produce a clear color still photo that is aminimum of ninety-six hundred (9600) dpi from any camera image, either live or recorded. All cameraswill capture at least thirty (30) frames per second. Pursuant to 3796:6-3-16 (e) (13), a date and timestamp will be embedded on all recordings. The date and time will be synchronized and set correctly
and will not significantly obscure the picture.Pursuant to 3796:6-3-16 (e) (15) All video surveillance equipment will allow for the exporting of stillimages in an industry standard image format, including .jpg, .bmp, and .gif. Exported video will havethe ability to be archived in a proprietary format that ensures authentication of the video andguarantees that no alteration of the recorded image has taken place. Exported video will also have theability to be in an industry standard file format that can be played on a standard computer operatingsystem. All recordings will be erased or destroyed prior to disposal.Attendance logs:APPLICANT will retain all records electronically unless prohibited by law. APPLICANT will use asecure internal server to store all attendance logs. Only the CDO and DR will have access to theattendance logs, and only to the minimum extent necessary.
Quality Assurance Review Logs:APPLICANT’s DR will ensure electronic copies of all quality assurance review logs are retained for aperiod of five (5) years and are accessible to the Board upon request. The logs will be maintainedonsite on a local server, unless APPLICANT is granted approval by the Board to store the records witha third-party vendor.Non-electronic versions of any quality assurance logs or supporting documents relating to the logs willbe scanne
Operations Plan(Other )
D-10.1 Please provide a summary of any other services or products to be offered by the Applicant atthe dispensary. OAC 3796:6-2-02
D-10.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-10.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
D-10.2 Please provide a summary of intended services for veterans and/or the indigent. OAC 3796:6-2-02; OAC 3796:6-3-22
APPLICANT’s Medical Advisory Committee includes a physician and medical director of a largeregional substance abuse clinic. Widely regarded as one of the most respectful authorities insubstance abuse counseling in Ohio, Medical Advisor Committee Member has co-authored bookchapters, published peer-reviewed editorials in leading journals, and is a clinical expert retained bypatient care societies for her specialization.In a collaborative effort, APPLICANT’S Chief Dispensary Officer (CDO) and Medical AdvisoryCommittee Member will offer counseling services and education on drug addiction and recovery. On atleast a bi-monthly basis, APPLICANT will host local meetings and educational seminars addressingsubstance abuse issues in the local community. Those in attendance will be provided with referrals tolocal substance abuse centers, therapists, and information on different modalities addressingsubstance abuse.In addition, APPLICANT will enact a community benefits plan with a special commitment to diversity.APPLICANT will offer the following diversity statement: “Agri-Med Enterprises devoted to building adiverse environment, and is committed to equal opportunity employment throughout the organization.The commitment to equal opportunities and diversity also applies to vendors, suppliers andindependent contractors.”Specifically, APPLICANT endeavors to hire at least 50% of its staff from the community directlysurrounding the dispensary (within a 10-mile radius). Further, APPLICANT is committed to maintainingthe highest standards in recruiting from a diverse cross section of the population. Currently,APPLICANT is committed to hiring at least 50% of its staff from historically underrepresented andunderserved groups.APPLICANT has committed to contributing 1% to 3% of its pre-tax income annually to the community,and will work with local leaders to establish a board of trustees to administer and distribute thesefunds. Preliminarily, APPLICANT has identified contributions to local law enforcement as one of theprimary beneficiaries of its contributions.APPLICANT will encourage its employees to recommend candidates for our open positions, leading toan employment increase in the community. It will also work with Ohio Department of Job and FamilyServices (ODJFS) to help adhere to our Diversity Employment Practices by finding qualified jobseekers to submit employment applications. APPLICANT’S contractors and subcontractors will beaccountable for complying with affirmative action and equal employment opportunity (EEO)requirements in accordance with the State of Ohio's affirmative action program. APPLICANT will verifythat policies and procedures to prevent workplace discrimination, harassment, intimidation, andcoercion are adhered to.APPLICANT has set a first-year goal to award contracts to minority or women-owned businesses,many of which are certified in the State of Ohio's Encouraging Diversity, Growth and Equity (EDGE)program when possible.
No response provided by applicant
APPLICANT will offer reduced rates for veterans, as defined by Ohio Administrative Code (OAC)
D-10.3 Describe the Applicant's efforts to minimize the environmental impact of the proposeddispensary. OAC 3796:6-2-02
§3796:7-1(I,) towards the purchase of medical marijuana and medical marijuana products.APPLICANT will purchase online and print advertising spaces to ensure that veterans are aware of itsreduced rates coupons. Individuals demonstrating service in the armed forces as defined by OAC§3796:7-1(I) will be provided with a 15% discount on all medical marijuana purchases.APPLICANT will offer free bi-monthly seminars to employees, patients/caregivers, and their families onPTSD in veterans to help foster a deeper understanding, empathy, and awareness. APPLICANT willexplain the causes and explore which products have had the highest success rate. Employees will berequired to attend at least one mandatory training session per year related to veterans’ issues and theimpacts of medical marijuana in the veteran community.APPLICANT will offer a similar discount program for individuals defined as “indigent.” Indigence will bedefined as income not exceeding 150% of the federal poverty line for the family size equal to the sizeof the person’s family. Using the federal poverty guideline for 2016, an individual demonstrating inincome less than $17,820 will qualify for an indigency discount.To qualify for an indigency discount, individuals must demonstrate that they meet the income basedcriteria established by APPLICANT. Means of proving indigency include, but are not limited to, thefollowing: salary or wages, Social Security income, worker's compensation benefits, pension andretirement benefits, interest income, financial support from family or friends, and any other income fromany source.APPLICANT will not allow any other form of coupon or discount other than those referenced herein.
APPLICANT will engage Green Globe Certification or a consultant group of equal or greaterexperience to ensure mitigation of any environmental impact created by the dispensary. Theconsultants will develop a structured baseline environmental sustainability program / certification thatapplies 44 criteria supported by 380 compliance standards, addressing operations and management.Energy, waste, water and other natural resources are at the forefront the program’s assessment andbaseline. APPLICANT intends to harmonize its baseline program with other cultivation, processing anddispensary licensees in Ohio via alliance groups and seminars.
The first step toward embracing sustainable business practices entails creating a sustainabilitymanagement system (SMS) that includes transparent, documented policies and procedures,implementation and communication plans. APPLICANT’S well written sustainability policy will defineand clearly communicate organizational goals and objectives as they relate to the business‚environmental, socio-cultural, and economic performance. The primary purpose of the sustainabilitymanagement plan is to guide decision-making, implementation, and the daily operations of theAPPLICANT in a sustainable manner.
State and local legislation and regulation addresses many of the social and environmental practicesassociated with marijuana operations. These include diversity, discrimination, health and safety, workhours and minimum pay. APPLICANT’S criteria is a complementary instrument that fills voids in therelevance, adherence and enforcement of critical social and environmental protections.
The success of the APPLICANT’S sustainability management system depends on the effectiveintegration and internalization of the system by employees at all levels. APPLICANT’S commitment tosuch endeavors will be evidenced by the “tone-at-the top” of management who will actively participatein the SMS program. A defined training program for all employees on the SMS aspects will enableemployees to understand the business’ goals and objectives, why they’re important, and how they canpositively contribute to the business’ efforts in each of their individual roles.
D-10.3.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-10.3. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
The construction experience of the CEO will ensure environmentally and economically sound designand development techniques are integrated into the design and building phase of the dispensary.Considerations will take into account minimizing natural resource impacts while concurrently optimizingsocio-cultural and economic benefits.
This includes:
• Use of locally appropriate tools and materials that minimize environmental impact• Integration of locally appropriate technologies in construction and finished facilities, includingindigenous materials• Development of local capacity – education, knowledge and experience – to use the materials,technologies, tools for sustainable construction• Local involvement of all concerned stakeholders in the process of adoption and implementation ofsustainable construction principles.
Enhancing the aesthetic, cultural, historic, and natural assets of the location as well as ensuring thatbuilt dispensary and operations do not negatively impact adjoining lands and people is also animportant factor for APPLICANT’S sustainable design.
APPLICANT will adhere to Ohio Environmental Protection Agency (EPA) rules and guidelines, and iscommitted to ensuring that there will be no significant adverse environmental impacts due to itsoperations. APPLICANT is committed to implementing preventative measures that will eliminate andreduce the potential risk of significant adverse environmental impacts.
APPLICANT’S environmental baseline program will also consist of energy audits and benchmark withthe utility providers to confirm performance is meeting or exceeding industry standards. APPLICANThas procurement processes in place to make use of locally sourced materials during construction andoperations to reduce the amount of transportation required and provide local businesses with economicopportunities.
During its construction phase, APPLICANT will use energy efficient spray foam insulation (equal orgreater than an R60 Rating) throughout the building to ensure proper retention of heat during thewinter months. Furthermore, APPLICANT will install energy efficient glass in all windows and otheropenings throughout the facility. APPLICANT will use low-watt lights to illuminate the building andfeature low-flow toilets in the restrooms. APPLICANT’s experts will perform commissioning on allbuilding systems to ensure industry compliant, efficient operation.APPLICANT will specify and procure recycled construction materials including concrete and syntheticmaterials as well as use adhesives, paints, and coatings with a low volatile organic compound (VOC)content to improve air quality. The facility will feature an on-site recycling center for all materials usedin the facility that can be recycled per Ohio state guidelines.APPLICANT has established a waste disposal system to ensure that waste produced by the facility isdisposed of in a way that effectively destroys the waste and complies with all state and local laws. Byproperly removing and disposing of litter and waste, APPLICANT minimizes the development of odorand the potential for attracting and harboring pests.
No response provided by applicant
Operations Plan(Security & Infrastructure Records )
D-11.1 By selecting "Yes", the Applicant attests that all responses identified as containing security andinfrastructure are voluntarily submitted to the State Board of Pharmacy in expectation of a protectionfrom disclosure as provided by section 149.433 of the Revised Code. YES
Patient Care(Staff Education and Training)
E-1.1 Describe the Applicant's education and training plan and how it will meet the foundational andongoing training required for dispensary employees to be authorized to dispense medical marijuana.Include a summary of the substantive training content, the number of hours each dispensary employeewill receive for each mandatory training requirement, the number of training hours each dispensaryemployee will receive for any elective training, and the anticipated source of each type of trainingdescribed. OAC 3796:6-3-19 APPLICANT’S executive team and Medical Advisory Committee will work in cooperation to create anindustry leading education and training plan. APPLICANT’S Chief Compliance Officer (CCO), apalliative medicine clinical pharmacist, will lead the team in ensuring that all education and trainingrequirements are exceeded. The Designated Representative will assume many of the day to dayresponsibilities of providing the training as dictated by APPLICANT’S executive team.Pursuant to §3796:6-3-19(H) of the Ohio Administrative Code (“OAC”), at least 60 days prior to thedispensing of medical marijuana, APPLICANT will seek Board’s approval of all written and electronicmaterials to be used in the training and education of APPLICANT employees. At a minimum,APPLICANT will apprise the Board of the name and qualifications of the person responsible forcreating the training materials; training objectives; the number of intended trainings to be completed forthe following 12-month period including the number of participants, brochures, the methods in whichthe materials will be presented, agendas, and, if requested, a set of training materials.Separately, in accordance with OAC §3796:6-3-19(G), APPLICANT will provide the Board with asigned attestation from a pharmacist or professional qualified to prescribe medicinal marijuanapursuant §4729(I), attesting that the professional is responsible for and approves of training contentrelating to (C)(3)(b), (C)(7), and (E)(1) to (E)(4).Upon Board approval, employee foundational training on the dispensing of medical marijuana willcommence. Pursuant to 3796:6-3-19 (A) and (B), APPLICANT’S dispensary will retain evidence of alltraining provided for every dispensary employee in its files, which are subject to inspection and audit bythe state board of pharmacy. At a minimum, the following records will be maintained for audit by theBoard.(1) Transcripts;(2) Certificates of completion; or(3) Other form of documentation which includes:(a) The participant's name;(b) Course title;(c) Course content;(d) Date(s) of training;(e) Provider's name(s); and(f) Signature of the course instructor.Employees will not be permitted to dispense medical marijuana until the following training protocol hasbeen completed:In accordance with OAC §3796:6-3-19(C)(1), employees will receive two (2) hours of annual trainingfrom a qualified, designated representative related to the OARRS system, including relevant training onthe drug database established pursuant to section 4729.75 of the Revised Code and be encouraged toengage in Q&A sessions following the training. Employees will receive a copy of the Ohio OARRSUser Support Manual, along with an abridged version with key points highlighted.In accordance with OAC §3796:6-3-19(C)(2), Employees will receive two (2) hours of annual trainingfrom the Designated Representative on the inventory tracking system established pursuant to§3796.17 of the Ohio Revised Code (“ORC”) covering, at a minimum: tracking medical marijuana fromreceipt at the dispensary to the time it is dispensed; record of each sale, purchase, and return ofproduct in the inventory tracking system; logging of all returns, waste, and unusable product; and
E-1.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-1.1. The images or diagrams may contain a brief descriptive caption. Additional
recording procedures related to the destruction of medical marijuana.Pursuant to OAC §3796:6-3-19(C)(3)(a), employees will receive a 2-hour presentation annually relatedto the toll-free telephone line established by the Board to respond to inquiries from patients, caregivers,and health professionals on adverse reactions to medical marijuana and to provide information aboutavailable services and assistance. Employees will have a laminated index card bearing the toll-freenumber.In accordance with §3796:6-3-19(C)(5), employees will receive two (2) hours of annual in-persontraining on the confidentiality requirements of APPLICANT. Employees will not be permitted todispense medical marijuana unless he or she scores an 85% on an examination following the training.In accordance with §3769:6-3-19(C)(6)-(8), employees will receive two (2) hours of annual in-persontraining on the forms, methods, strains, and authorized uses of medical marijuana. Employees will beprovided with a written matrix for reference.In accordance with §3769:6-3-19(C)(9)-(10), employees will receive two (2) hours of annual training onlegal and regulatory matters; including, but not limited to, regulatory inspection preparedness, lawenforcement interaction, and the legal requirements for maintaining status as a licensed dispensaryemployee. Employees will be provided with the OAC §3796 in its entirety, along with an abridgedversion tailored to the Employee’s position.Biennially, APPLICANT will require a minimum of sixteen (16) hours of in-house annual training andeducation for each dispensary key and support employee, with at least two (2) hours of training perquarter. Employees failing to complete the minimum hours of training required pursuant to §3769:6-3-19(D) will not be permitted to dispense medical marijuana.APPLICANT will provide a minimum of two (2) hours of annual in-person training compliant with OAC§3796:6-3-19(G) on each of the following:1. Guidelines for providing information to patients and caregivers related to risks associated withmedical marijuana, including possible drug interactions;2. Guidelines for providing support to patients related to the patients' symptoms;3. Recognizing signs and symptoms of substance abuse;4. Guidelines for refusing to provide medical marijuana to an individual who appears to be impaired orabusing medical marijuana;APPLICANT will provide a minimum of two (2) hours annually of either in-person or Internet-basedtraining related to:1. The safe handling of medical marijuana, including an overview of common industry hazards, currenthealth and safety standards, and dispensary best practices;2. Legal updates training pertaining to the Ohio medical marijuana control programAPPLICANT’S Designated Representative, in cooperation with a pharmacist or professional qualifiedto prescribe medicinal marijuana pursuant §4729(I) will (at least biannually) develop and disseminateeducational materials for patients and caregivers and a system for patients and/or caregivers to trackthe use and effects of medical marijuana. The Designated Representative will provide employees withinformational brochures and pamphlets related to recognizing the signs and symptoms of substanceabuse and information related to opportunities to participate in substance abuse programs. TheDesignated Representative will also create and implement a plan to disseminate information fromemployees to patients assisting patients and caregivers in documenting patient symptoms using a logbook.The Designated Representative will maintain all education and training materials required under§3796:6-3-19(N) in accordance with OAC §3796:6-3-19(O).APPLICANT is aware that in accordance with §3769:6-3-19(L), the Board, upon receipt of evidencethat any approved training program or training provider is not conforming to the requirementsdeveloped pursuant to this rule, may revoke or otherwise limit the scope of the Board’s prior approval.
language responding to the question will not be considered.
E-1.2 Summarize how the Applicant's training plan will identify and incorporate advancements inmedical marijuana research. Include a description of the frequency with which the training plan will beupdated, how new information will be incorporated into the training plan, the method for providingupdated training to dispensary employees, and the frequency with which updated training will beprovided to dispensary employees. OAC 3796:6-3-19
No response provided by applicant
APPLICANT’S executive and advisory team consists of professionals collectively holding over acentury of experience in education, training, and organizational leadership.APPLICANT’S Chief Science Officer (CSO), is an active, tenured associate professor in the surgerydepartment at a world-class hospital and has mentored no less than six (6) physicians at the formativestage of their careers. The CSO has held funding from the American Heart Association and theNational Institutes of Health for phytochemical therapeutics. CSO is also actively involved in peerreview committees, editorial boards, and grant review boards. Since 2015, CSO has dedicatedsignificant time to the research of medical marijuana and actively follows advancements in medicalmarijuana research.APPLICANT’S CSO, CCO, and Designated Representative, in cooperation with a pharmacist or otherprofessional qualified to prescribe medication under Ohio Administrative Code (“OAC”) §3796:6-3-19(G), will create and implement systems to track and incorporate advancements in medical marijuanaresearch. At a minimum, APPLICANT will utilize the following resources to identify any advancementsin medicinal marijuana research:• APPLICANT’S Executive Team and Advisors: No less than every six months, APPLICANT’Sexecutive and advisory team will meet either in-person or through video conferencing to discussadvancements in medical marijuana research. APPLICANT’S CCO and CSO will be assigned primaryresponsibility for agenda development and education of the executive team.• Retention of Industry Experts: At least once per year, the Designated Representative and one othermanagement staff shall receive three (3) hours of live, in-person training from a qualified third-partyvendor, pharmacist, or professional qualified to prescribe medication pursuant to §3796:6-3-19(G)regarding advancements in medical marijuana research.• Trade Journals: The APPLICANT shall subscribe to various trade journals, including, but not limitedto, Cannabis Business Times and the Cannabis Industry Journal.• Conferences and events: The Designated Representative and at least one other management staffmember shall attend at least one conference or event per year directly related to advancements inmedical marijuana research. If no conference or event related to advancements in medical marijuanaresearch is hosted in a particular year, then the Designated Representative and management staffmember shall be permitted to view a minimum of five (5) hours of video training online in lieu of theconference.• Online Education: The Designated Representative shall complete at least five (5) hours of onlinetraining per year related to any advancements in medical marijuana research.• Peer Reviewed Studies: All relevant peer-reviewed studies discovered by the APPLICANT shall bemade available to all employees electronically. Employees may request a copy of the study, whichshall be provided within forty-eight hours (48) hours of request.Upon identifying advancements in medical marijuana research, the Designated Representative willconsult with the pharmacist or other professional qualified to prescribe medication pursuant to OAC§3796:6-3-19(G) to discuss implementation of relevant advancements in the APPLICANT’s trainingprogram. Specifically, APPLICANT will endeavor to implement changes to the training program that arepeer-reviewed and backed by substantial evidence.The APPLICANT training program will be updated annually to reflect relevant advancements made in
E-1.2.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-1.2. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
the areas of medical marijuana research. At a minimum, training materials will be amended toincorporate new information related to the efficacy of medicinal marijuana treatment, modes ofadministrations, potency implications, and risks of cannabis consumption.Training materials, including, but not limited to, employee handbooks, SOP’s, internal training videos,management training materials, and other written and electronic documents that contain informationrelated to the benefits and risks of marijuana consumption will be amended. The amended documents,both written and electronic, will be monitored and tracked via an excel spreadsheet. At least one uppermanagement team member will assist in ensuring all changes reflecting advancements in medicalmarijuana research are made to the documents.All documents updated by APPLICANT to reflect advancements in medical marijuana research shall bedisseminated to employees within fifteen (15) days of being altered. APPLICANT will ensure that eachemployee receiving an updated document executes a written confirmation acknowledging receipt andreview of the materials. For certain notable advancements impacting patient health, employees willreceive a minimum of one hour of in-person training by the Designated Representative or his or herdesignee. Employees shall execute a separate confirmation acknowledging the training.Within twelve months of operation, APPLICANT will create, cause to be created, or will obtain a third-party license for an “e-learning platform.” The platform, when implemented, will provide APPLICANTwith a central repository of training materials accessible by all employees on a 24/365 basis.Furthermore, the platform will allow for more rapid dissemination of any new or amended trainingmaterials delivered immediately to employee email accounts.APPLICANT will also implement a “train the trainer” protocol to ensure the downstream disseminationof accurate and up-to-date information. Specifically, the Designated Representative, his/her designee,and at least one other member of the management staff will be trained by a qualified third-partyvendor, pharmacist, or other professional qualified to prescribe medication under OAC §3796:6-3-19(G) on a yearly basis on the most recent advancements in medical marijuana research. APPLICANTshall endeavor to always provide in-person, classroom-style setting allowing question and answersessions.Notwithstanding the receipt and acknowledgement of updated training materials and/or training, allemployees requesting a copy of the updating training materials due to loss or theft shall within forty-eight (48) business hours be provided with the most recent versions of the training materials. Allemployees requesting “refresher” training on recent changes to the training manuals shall be providedsuch training within ten (10) business days by the Designated Representative or his/her designee.APPLICANT is aware that in accordance with §3769:6-3-19(L), the state board of pharmacy, uponreceipt of evidence that any approved training program or training provider is not conforming to therequirements developed pursuant to this rule, may revoke or otherwise limit the scope of the board'sprior approval.
No response provided by applicant
1.2.3.4.5.
Patient Care(Patient Care and Education)
E-2.1 Describe how dispensary employees will be trained to provide patient education regarding:Recognizing the signs of abuse or adverse events in the medical use of marijuanaInstruction on use of medical marijuana to treat a qualifying conditionRisks associated with medical marijuana, including possible drug interactionsGuidelines for support to patients related to the patient's symptomsGuidelines for refusing to provide medical marijuana to an individual who appears to beimpaired or abusing medical marijuana. Include the sources of the training and the sources'qualifications to provide such training.
Please reference OAC 3796:6-3-19 for more information. APPLICANT endeavors to take an interactive approach to patient education. APPLICANT will leveragethe experience of an interdisciplinary team that includes pain physicians, pharmacists, and scientistsfor the development of printed materials, online coursework, conferences, seminars, and peer-reviewed research to educate patients. Pursuant to 3796:6-3-19 (A) and (B), the dispensary willmaintain evidence of all training provided for dispensary employees, which will be subject to inspectionand audit by the State Board of Pharmacy (Board). The development of new hires will be overseen bya Chief Dispensary Officer (CDO) who has overseen and managed 19 pharmacies in Ohio, and willharness the assistance of the Designated Representative (DR).The Designated Representative will work in cooperation with the Chief Compliance Officer (CCO) whohas participated and directed research projects that have focused on using an FDA approved syntheticformulation of THC. Professionals qualified to prescribe medication under OAC §3796:6-3-19(G) mayassist APPLICANT in providing training on the following:1. Recognizing the signs of abuse or adverse events in the medical use of marijuana;2. Instruction on use of medical marijuana to treat a qualifying condition;3. Risks associated with medical marijuana, including possible drug interactions;4. Guidelines for support to patients related to the patient's symptoms; and5. Guidelines for refusing to provide medical marijuana to an individual who appears to be impaired orabusing medical marijuana.Prior to the commencement of any training regimen and pursuant to §3796:6-3-19(H) of the OhioAdministrative Code (“OAC”), at least 60 days prior to the dispensing of medical marijuana,APPLICANT will seek the Board’s approval of all written and electronic materials to be used in thetraining and education of the APPLICANT’s employees. At a minimum, APPLICANT will apprise theBoard of the name and qualifications of the person responsible for creating the training materials, theobjectives of the training, the number of intended trainings to be completed for the following 12-monthperiod including the number of participants, brochures, the methods in which the materials will bepresented, agendas, and if requested, a set of the training materials.In accordance with OAC §3796:6-3-19(G), APPLICANT will provide the Board with a signed attestationfrom a pharmacist or professional qualified to prescribe medicinal marijuana pursuant §4729(I),attesting that the professional is responsible for the training content relating to this inquiry.APPLICANT’S Medical Advisory Committee, which is comprised of physicians with extensiveexperience with substance abuse treatment/prevention, will help to guide strategy and set policyrelated to research activities, education efforts, and health issues. APPLICANT will retain at least onerecognized expert on the behavioral pharmacology of cannabis to serve as an educational consultantand advisor on matters related to substance misuse and addiction. The expert will have conductedcontrolled research on acute cannabis intoxication, cannabis withdrawal, and evidence-basedtreatments for cannabis and other substance use disorders. The expert will coordinate with Applicant’sDR to implement additional educational and training initiatives.Annual training from local law enforcement officers will be provided on:1. Current local substance abuse trends;
1.2.
3.
E-2.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-2.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
E-2.2 Describe the Applicant's processes, procedures and controls addressing reports of adverseevents. Include, at a minimum, a description of:
How reports will be documentedThe circumstances that will require reports of adverse events will be reported to a cultivator,processor, and / or the State Board of PharmacyThe time frame for which to provide such reports
2. The type of behavior exhibited by individuals who are under the influence of substances abuse;3. How to safely respond when confronted with such an individual, and4. Emergency preparedness in case the individual becomes aggressive or experiences medicalcomplications.Along with the assistance of local treatment centers and medical schools, APPLICANT’S clinicalexperts will host educational seminars with addiction experts from local medical schools and addictiontreatment centers with an emphasis on cannabis and opioid use disorders. APPLICANT’S ChiefMedical Officer (CMO) has paved the way in working to develop non-opiate medication for pain,assisted with growing a regional hospital, and developed safety protocols and treatment for painpatients. Another member of APPLICANT’S Medical Advisory Committee directs a substance abusetreatment and prevention program at a large regional university, and is widely recognized as anaddiction expert. APPLICANT’S CDO is a clinical pharmacy specialist in pain medicine and palliativecare has participated and directed research projects that have focused on using an FDA approvedsynthetic formulation of THC in an off-label fashion for opioid weaning. APPLICANT will host experts inother areas of addiction as needed.Staff will be trained on an ongoing basis on how to talk to individuals suspected of misusing cannabis(or other substances), and how to use existing resources to provide treatment referrals. The DR will berequired to complete continuing medical education courses related to addiction annually.The DR will establish and maintain communication with local substance abuse treatment centers toascertain ongoing rates of cannabis misuse among individuals involved with the medical cannabisprogram, and the type and severity of problems experienced by those individuals.Monthly staff meetings that last a minimum of 2 hours will occur in which the DR will lead staff in areview of incidents related to intoxicated individuals or cases of confirmed or suspected substancemisuse. The DR will also educate staff on relevant new information on marijuana or other drug misuseamong medical marijuana patients derived from reviews of the scientific literature. Relevant printed andweb-based resources will be provided.
No response provided by applicant
General Overview: APPLICANT strives to avoid all adverse events, including, but not limited to, thesale of marijuana or marijuana products where evidence exists that:• Unauthorized pesticides were used or later become present on the marijuana plant material sold topatients or caregivers,• Unauthorized pesticides were used or later became present on marijuana plant material that werelater manufactured and used in a product administered through a different mode,• Any other condition that poses a risk to public health or safety.Documentation: A web-based internal reporting system will be utilized by APPLICANT to ensure alladverse events are immediately and thoroughly documented. Upon receiving notice from a patientand/or caregiver of an alleged adverse event, the following information will be gathered byAPPLICANT’S Designated Representative and/or Chief Dispensary Officer (CDO):
1. Name of patient and/or caregiver;2. Obtain other patient identifier information;3. Location of purchase, date of purchase;4. Time of purchase;5. Name of the dispensary employee transacting the sale;6. Whether the purchase was of marijuana or a marijuana product;7. The strain or type of marijuana or marijuana product;8. The alleged adverse symptoms experienced by the patient;9. The time the patient first began to experience the adverse symptoms;10. Whether the patient has sought the advice of medical professionals;11. Whether the medical marijuana or marijuana product has been discarded; and12. Whether the patient and/or caregiver intends to return the marijuana to APPLICANT.Through administrative and technical safeguards (e.g. providing only those employees with a need forreporting with login access and only to the minimum extent needed to complete accurate reporting)APPLICANT will ensure that patient and/or caregiver reports are timely processed, while preservingconfidentiality to the extent permitted by law. No employee will be permitted to delete the report of anadverse event and any attempts to delete a record of an adverse event will result in employeediscipline, up to and including termination.APPLICANT CDO will ensure that all software, hardware, data storage, and other systems arecompliant with the federal Health Information and Portability Act ("HIPAA") as defined by 45 C.F.R. part160 and in 45 C.F.R. part 164, subparts A and E, and Chapter 37 of the Ohio Revised Code. Anybreaches in patient confidentiality will be reported and remediated in manners prescribed by state andfederal law.APPLICANT'S Designated Representative will also serve as the Notification Coordinator for purposesof notifying cultivators, processors, and the State Board of Pharmacy. The Notification Coordinator willprovide APPLICANT with a telephone number where he/she can be reached 24 hours a day, 7 days aweek for purposes of notifying the State Board of Pharmacy of any reports of adverse events.Notification to Board of Pharmacy: Pursuant to OAC 3796:6-3-11(G), upon notification of a seriousadverse event from a patient, caregiver, or other third party, APPLICANT, through its DesignatedRepresentative, will make a report to the Ohio Board of Pharmacy ("Board") of the event though use ofa toll-free telephone line established by the Board. APPLICANT will cooperate in any Boardinvestigation related to the alleged adverse event and will make all disclosures to the Board aspermitted by law.Notification to cultivators and processors:APPLICANT'S CDO and Designated Representative will identify the batch or other source from whichthe medical marijuana or medical marijuana product was dispensed. A supervisor present at thedispensary will immediately halt sales of the marijuana or marijuana product alleged to have causedthe adverse event. The same product will not be sold or otherwise dispensed to other patients orcaregivers until APPLICANT, in cooperation with the cultivator and/or processor conducts a reasonableinvestigation and the marijuana or marijuana product is deemed safe for consumption. APPLICANT willretain a record of all oral and written communications with cultivators and processors related toallegations of adverse events for a period of not less than 72 months and will provide such records tothe Board upon request to the extent permitted by law.Consumer Notification: In accordance with 3796:6-3-15(F), APPLICANT will post a visible andunobstructed sign directing patients and caregivers with medical marijuana-related inquiries or reportsof adverse reactions to the toll-free telephone line established by the state board of pharmacy inaccordance with section 3796.17 of the Revised Code. APPLICANT will also provide the patient and/orcaregiver reporting the adverse event with the toll-free telephone number established Board at the timethe adverse event is reported.
1.2.3.4.
Patient Care(Patient Care Facilities)
E-3.1 Describe the adequacy of the size of the proposed dispensary to serve the needs of patients andcaregivers, including building and construction plans with supporting details. Such plans shall illustrate,at a minimum, the size and location of the following within the prospective dispensary location:
The dispensary departmentRestricted access areasWaiting roomPatient care areas or other areas designated for patient and caregiver consultation andinstruction. Include a summary of the patient flow through each area, the maximum patientand caregiver occupancy in each area at any given time, the amount of time the Applicantexpects to interact with both new and returning patients, and the number of dispensaryemployees who will staff each area
Please reference OAC 3796:6-2-02 for more information. APPLICANT has retained Janjic Architecture to design a 2,500-square foot state of the art dispensarywith ample space throughout the facility to accommodate patient comforts, while preventing theunlawful diversion of medical marijuana. As demonstrated in more detail in the attached building plans,APPLICANT’S dispensary will provide barriers between the key limited access and restricted roomswithin the facility and will provide secure storage of its medical marijuana.APPLICANT will provide a controlled, secured flow throughout the dispensary ensuring that access isgranted only to employees with specific access badges and patients/caregivers possessing validregistrations. The dispensary will include two areas where registrations will be inspected and verified.1) the lobby area and 2) at the point of sale. Dispensary support employees will be trained to recognizebreaches of the patient flow and will immediately report any breaches to the DesignatedRepresentative and/or the Chief Dispensary Officer.Lobby Area:Patients and caregivers will enter the dispensary through the lobby. Upon entering the lobby, patientsand/or caregivers will be required to demonstrate a valid, active registration card prior to entry into thedispensary waiting room. The reception area is designed such that the receptionist whom is physicallysituated in the security room (separated by a wall) will greet the patient and caregiver through asecured sliding protected window. Security surveillance will be present in the reception area. If thepatient and/or caregiver present valid documentation, the Receptionist will buzz in and allow for thepatient/caregiver to advance into the waiting room though a secured door.Those individuals unable to demonstrate an active registration will not be permitted into the dispensarywaiting room and will be asked to leave the dispensary.APPLICANT anticipates the verification of active registration will take approximately fifteen minutes perpatient and five minutes for returning patients.The lobby will be staffed by one dispensary support employee. APPLICANT may later elect to place asecurity professional within the lobby to deter diversion and loitering.The lobby area will be 50 sq. ft. and will have a maximum occupancy of two patients and/or caregivers.Waiting Area:After verification of an active registration card, patients and/or caregivers will enter the waiting area.The waiting area can accommodate up to eight people at a time; however, APPLICANT anticipatesthat no more than six patients and/or caregivers will be permitted into the area at once.APPLICANT endeavors to maintain a wait time of no longer than fifteen (15) minutes within the waitingroom. The waiting room will not have a dispensary support employee present.The waiting area will be 400 sq. ft. and will have a maximum occupancy of eight patients and/orcaregivers.Adjacent to the waiting are is a unisex bathroom measuring 80 sq. ft. and a patient consultation room
E-3.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-3.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
measuring 120 sq. ft.Patient Consultation Areas:Upon entering the waiting area, patients and/or caregivers will have the option of receiving aconsultation in the patient consultation area. The patient consultation area will be separate from theremaining room with a lockable door at its entrance.The patient consultation area will include a desk, three chairs, and a desktop computer. The patientconsultation area is 120 sq. ft. and will have a maximum occupancy of three individuals (1 patient, 1caregiver, and 1 dispensary employee).Dispensary:If the dispensary is below its maximum occupancy of twelve patients/caregivers, those in the waitingarea will be permitted to enter the dispensary until the maximum occupancy is reached. Thedispensary will be staffed by up to five dispensary support employees and the DesignatedRepresentative.APPLICANT expects that new patients/caregivers will interact with dispensary employees for anaverage of twenty minutes during their first visit, while returning patients/caregivers will interact with thedispensary employees for an average of ten minutes.The dispensary area will be 1200 sq. ft. and will have a maximum occupancy of 20 individuals (12patients and/or caregivers, 5 dispensary employees, 1 Designated Representative, 1 Security Guard,and 1 Chief Dispensary Officer.)Once inside the dispensary room, patients/caregivers will be greeted by a dispensary supportemployee. The patient/caregiver will be able to inquire with the dispensary employee about the varioustypes of medical marijuana and medical marijuana products. If electing to purchase medical marijuanaor medical marijuana products, the patient/caregiver will be directed to an available client servicestation where the patient’s registration card will once again be verified.Exiting the Facility:Patients/caregivers will exit the facility through the same route in which they entered. Thepatient/caregiver will depart from the point of sale station in the dispensary and head towards thewaiting room. Prior to exiting the dispensary, a staff member or security guard may verify thepatient/caregivers purchases prior to exit. Once in the waiting room, the patient/caregiver will continuethrough to the lobby area to the entrance/exit door located at the front of the facility.Back Office:The back office is a restricted area and is only accessible to key employees (Chief Dispensary Officerand Designated Representative). Access by all other employees and/or Patient/Caregivers is expresslyprohibited. Access to the back office from inside the dispensary area will be secured by a key cardaccess controlled door.The back office will have 2 desks, 2 chairs, 2 desktops computers, and 1 color multifunction printer.The back office is 200 sq ft and will have a maximum occupancy of 4 individuals. Although only keyemployees will be allowed into the back office, the APPLICANT is taking into consideration theprobability of state designated employees, Law Enforcement, and or Fire Chief Inspectors requestingaccess to the area.Safe:The Safe is the most secure area of the Dispensary. It is only accessible by key employees (ChiefDispensary Officer and Designated Representative) and is located within the Back Office. This iswhere all inventory and cash will be securely stored on shelves during and after business hours. Inaddition, the Security Camera Network Video Storage Device, Backup Battery, Alarm Control Panel,and Security Monitor will also be housed in the safe. Access to the safe is controlled by a commercialgrade access control door. The total size of the Safe is 100 sq ft.
No response provided by applicant
Patient Care(Dispensary Operating Hours)
E-4.1 By selecting "Yes", the Applicant attests that it will make the dispensary available to patients andcaregivers to purchase medical marijuana for a minimum of 35 hours per week, between the hours of 7am and 9 pm, except as authorized by State Board of Pharmacy. OAC 3796:6-3-03
E-4.2 Provide the proposed hours of operation during which the prospective dispensary will available todispense medical marijuana to patients and caregivers. (Information only) OAC 3796:6-3-03
YES
7 a.m. to 9 p.m.
Patient Care(Patient Information)
E-5.1 By selecting "Yes", the Applicant attests that it will post a sign directing patients and caregiverswith medical marijuana inquiries or adverse reactions to the toll-free hotline established by the StateBoard of Pharmacy. OAC 3796:6-3-15
E-5.2 By selecting "Yes", the Applicant attests that it will make information regarding the use andpossession of medical marijuana available to patients and caregivers. The Applicant agrees to submitall such information to the State Board of Pharmacy prior to being provided to patients and caregivers. OAC 3796:6-3-15
YES
YES
Attestations and Acknowledgements(Attestations and Acknowledgements)
F-1.1 Fill out and attach the “Trade Secret Form” to Question F-1.1, specifying the question and / orattachment references of the application submission that are exempt from disclosure under Ohio publicrecords law and articulate how the information meets the definition of “trade secret” under OhioRevised Code section 1333.61(D). If no material is designated as trade secret information, a statementof “None” should be listed on the form. Uploaded Document Name: F-1.1_Trade Secret Form.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
F-1.2 To be considered complete, each application must be submitted with an Attestation and ReleaseAuthorization. The form must be completed by a Prospective Associated Key Employee who maylegally sign for the Applicant and who can verify the information provided in the application is true,correct, and complete. This response has been entirely redacted