the commonwealth of massachusetts...please note that no executive, member, or any entity owned or...

CHARLES D. BAKER Go11emor

KARYN E. POLITO Ueut.l"llWlt Govemor

INSTRUCTIONS

#2of 3

The Commonwealth of Massachusetts Executive Office of Health and Human SeNices

Department of Public Health Bureau of Health Care Safety and Quality

Medical Use of Marijuana Program 99 Chauncy Street, 111t1 Floor. Boston, MA 02111

APPLICATION OF INTENT Request for a Certificate of Registration to

Operate a Registered Marijuana Dispensary

MARYLOU SUDDERS Secretary

MONICA BHAREL, MO, MPH Commlnlonar

Tll: llt7160-6:17D - ...... u .gov/medic•lma'11111ne

This application form is to be completed by any non-profit corporation that wishes to apply for a Certificate of Registration Lo operate a Registered Marijuana Dispensary ("RMD") in Massachusens.

If seeking a Certificate of Registration for more than one RMD, the applicant non-profit corporation ("Corporation") must submit a separate Applicalion of /nlent, all required anachments, and an application fee for each proposed RMD. Please identify each application of multiple applications by designating it as Application I, 2 or 3 in the header of each application page. Please note that no executive, member, or any entity owned or controlled by such an executive or member, may directly or indirectly control more than three RMDs.

However, even If submitting an Applkatio11 of Intent for more than one RMD, an applicant need only submit one Characler and Competency form for each required individual.

Unless indicated otherwise, all responses must be typed into the application forms. Handwritten responses will not be accepted. Please note that character limits include spaces.

Attachments should be labelled or marked so as to identify the question to which it relates.

Each submitted application must be a complete, collated response, printed single-sided, and secured with a binder clip (no ring binders, spiral binding, staples, or folders).

Mail or hand-deliver the Applicalion of Intent, with all required attachments, the $ t ,500 application fee, and Remittance Form to:

Department of Public Health Medical Use of Marijuana Program

RMD Applications

:: )>

o::i

Cardiac Anflythmia Syndromes Foundalion, Inc. Application _2 _of _3 _ Applicant Non-Profit Corporation _3_ko_-_c_AS_F_oo_n_do_u_·0_0 _________ _

REVIEW

Applications are reviewed in the order they are received.

After a completed application packet and fee is received by the Department of Public Health ("Department"), the Department will review the information and will contact the applicant if clarifications/updates to the submitted application materials are needed. The Department will notify the applicant whether they have met the standards necessary to be invited to submit a Management and Operations Profile.

If invited by the Department to submit a Management and Operations Profile, the applicant must submit the Management and Operations Profile within 45 days from the date of the invitation letter, or the applicant must submit a new Application of Intent and fee.

PROVISIONAL CERTIFICATE OF REGISTRATION

Applicants have one year from the date of the submission of the Management and Operations Profile to receive a Provisional Certificate of Registration. If an applicant does not receive a Provisional of Certificate of Registration after one year, the applicant must submit a new Application of Intent and fee.

REGULATIONS

For complete infonnation regarding registration of an RMD, please refer to I 05 CMR 725. I 00.

It is the applicant's responsibility to ensure that all responses are consistent with the requirements of 105 CMR 725.000, et seq., and any requirements specified by the Department, as applicable.

PUBLIC RECORDS

Please note that all application responses, including all attachments, will be subject to release pursuant to a public records request, as redacted pursuant to the requirements at M.G.L. c. 4, § 7(26).

QUESTIONS

If additional infonnation is needed regarding the RMD application process, please contact the Medical Use of Marijuana Program al 617-660-5370 or RMDapplication

Cardiac Arrhythmia Syndromes Foundation, Inc.

Application _2 _ of_3 _ Applicant Non-Profit Corporation _aJc_a_-_c_A_s_F_o_un_d_nu_·0_" ________ _

CHECKLIST

The fonns and documents listed below must accompany each application, and be submitted as outlined above:

0 A fully and properly completed Application of lnlenl, signed by an authorized signatory of the corporation

0 A copy of the Corporation's Certificate of legal Existence from the Massachusetts Secretary of State

0 Financial account summary(ies) (as outlined in Section D)

0 A bank or cashier's check made payable to the Commomvea/th of Massachuselts for $1,500.

0 A completed Remillance Form (use template provided)

0 A completed and signed Character and Competency form (use template provided) for each of the following actors:

• Chief Executive Officer; Chief Operating Officer; Chief Financial Officer; individual/entity responsible for marijuana for medical use cultivation operations; individual/entity responsible for the RMD security plan and security operations; each member of the Board of Directors; each Member of the Corporation, if any; and each person and entity known to date that is committed to contributing 5% or more of initial capital to operate the proposed RMD. For entities contributing initial capital to operate the proposed RMD, the Character and Competency Form must be completed and signed by the entity's Chief Executive Officer/Executive Director and President/Chair of the Board of Directors.

Information on this page has been reviewed by the appli. where provided by the applicant, is accurate and complete, as indicated by the initials of the authorized signatory here

Application of Intent - Page 3

audiac Arrhythmin Syndromes Foundation, Inc. Application..:__ of

3 Applicant Non-Profit Corporation _llkn_-_c_A_s_F_ou_nda_ti_00 _________ _

SECTION A. APPLICANT INFORMATION

Cardiac Arrhythmia Syndromes, Inc. (aka - CAS Foundation) t.

Legal name of Corporation

2. Name of Corporation's Chief Executive Otlicer

3. 9 Bartlet Street Unit 335

6.

Andover, MA 01810

Address of Corporation (Streel, Cityffown, Zip Code)

Applicant point of contact (name of person the Department should contact regarding this application)

Applicant point of contact's telephone number

Applicant point of contact's e-mail address

7. Number of applications: How many Applications of Intent do you intend to submit? _3_

SECTION B. INCORPORATION

8. Attach a Certificate of Legal Existence from the Massachusetts Secretary of State, documenting that the applicant non-profit entity is incorporated as a non-profit in Massachusetts.

See attached •Articles of Organization"

SECTION C. CHARACTER AND COMPETENCY

9. Attach a Character and Competency form (use template provided) for each of the following actors:

• The Chief Executive Officer; Chief Operating Officer; Chief Financial Officer; individual/entity responsible for marijuana for medical use cultivation operations; individual/entity responsible for the RMD security plan and security operations; each member of the Board of Direclors; each Member of the Corporation, if any; and each person and entity known to date that is committed to contributing 5% or more of initial capital to operate the proposed RMD. For entities contributing initial capital to operate the proposed RMD, the CharacJer and Competency Fonn must be completed and signed by the entity's Chief Executive Officer/Executive Director and President/Chair of the Board of Directors.

Information on this page has been reviewed by the applicilill.and where provided by the applicant, is accurate and complele, as indicated by the initials of the aulhorizcd signatory here: --


#I

#2

#2a.

#3

#4

#4a.

#5

#6

#7

C:irdiac ArThythmin Syndromes foundation. Inc. Application L of_3 _ Applicant Non-Profit Corporation _n_1c.n_._c_A_s_Fou_ni_Jnrio_n ________ _

SECTION D. INITIAL CAPITAL REQUIREMENT

Describe the sources, types, and amounts of required initial capital in the table below, showing that the Corporation has nt leasl $500,000 in its control and available for this Application of Intent and at least $400,000 in its control and available For each additional Application of Inte111, if any, as evidenced by bank statements, lines of credit, or financial institution statements. Add more tables if needed.

If the required funds are being held in an account in the name of an individual or entity olher than the Corporation, the individual or authorized signatory of the entity must provide their signature in the "Signature of Account Holder" column. Their signature below indicates that they are committing the amount of their funds identified in the table to the applicant.

ln addition to completing this table, submit a on~page financial account summary for each account listed below documenting the available funds, dated no earlier than 30 days prior to the dale the Application of intent was submitted to the Department.

Financial Type of Amount

Institution Account

BANK OF Checking AMERlCA

Harriet Jacobs MERRILL LYNCH Investment Acct. Retirement

Harriet Jacobs PROFILE BANK Savings

Innocent Cambridge Savings Lugumamu Retirement Board

NORTHMARK Checking

NORTHMARK Checking ACN II

. Ralph & Andrea LPL FINANClAL Various (7) Caruso

May Chan Hui FIDELITY Various (4)

TOTAL:

PERSONAL LOAN Cash

TOTAL:

1nform:ition on this p11ge h11s been reviewed by the appli indicated by the init.ials of the authorized signatory here:

$ 167,133

$ 257.202

here provided by the applicant. is accurate and complete, as

Application of Intent - Page S

~~ BankofAmerica ~ l'.O. llo1' 152!14 Wiimington, OE 19ff..'i0

Your combined statement for May 20, 2015 to June 19. 2015

Preferred Rewards

Customer service lnfonnatlon

it 1.888.888.RWDS (1 .888.888.7937)

TDD/TTY users only: 1.800.288.4408

En Espanol: 1.800.688.6086

' bankofamerlca.com

Bank of America, N.A. P.O. Box 25118 Tampa. FL 33622-51 t B

:#/

Your deposit accounts Account/plan number Ending balance

SlOS,059.72

$1,242.61

S106,302.33

Details on

ScenicBanking - Spring BofA Enhanced -Checking

Regular Checking

Total balance

ARCSPWGX

Thank you and welcome to Preferred Rewards

Now you can earn more, save more and get more back for the everyday banking you do

Make sure you get the most out of your new benefits and rewards. Talk to a specialist at888.888.RWDS (888.888.7937)

bJnk of America NA. Member FDIC .0201 s Sank ()f America Corpor.iuon SSl-.H1· 14·0129Cl

Page3

Pages

Pvt.I.: D CYCJ.£: 13 SPEC: 0 0£UVERY. P TYPE: IMAClE· A BC: MA Page 1or10

Heao, HARRIET JACOBS - ............. ... ...... . t .... .

-···· ___._.._ .. ....... - ..,_•'-"• ..

....... ~. .. , ....

,__ .._.... ............. ._....__

=.....,.. ... .....__,_,.,.... ............... _ ........ _ ..... ....,._ , .. ~--·-........ -.....-....... -...-,,,...._,. ... _ .. ,_......,_ _ _......_,_..,. _____ .--. .._ ..__ ........... .. -.-.o. :--.... -:::-.:- _.."".C=.---...-.:==::.~-===-.. .... ....._ ..... .,._..,._ ... ._~ . ..._ ....... _~_ ~-------.......... _ _.~.....,--........, ................. _ '-·--·· .,. _______ .. _____ ,,__,... _________ ._ -·w...._. _ __,.,.... ....... _.i _____ ..................... ___ ....,.. ___ ~..._ • .,.._ ...... ._.,..,_ .._. _____ ,.....,__ ------.-----------·-·----_ _,_ _____ ,., _____ .. ____ ......,. ...... - ... -=~ ................ ,......, ___ ,_ _____ __,... ~--...... --..i..----0.....--... ,·---~-..... _...._,_ .. ..,..... ___ ,,,, .. _ .... ,...-..... ·~·-· ----··-----...... !!-............ _.. ....... .,._..._....,.. ___ ........ ·~·-"

-·-·._ .. --- ----................... """' ........ ... ,_.._,,. ... .,,.. ............. ...... .. -..... --·-""·----· ··~- ............. ___ .. = .......... .

--___ .._

·------.......... .., ............... ... ..,._.. ......... .._ ___ .._.... .•

......,..._.,.QA...__.......,. ~ ........ _____ _ .... ..._ ca... .................. .

-·-'"-~ -----·~..........................

~.,.._. ..._ . ...., ........ ..__.... ..... ,..... ..... -- ... ~ ·-·--_,. . ._ -- -c...-.. :._,. .__.. ·-·- ..... ..__...., ____ .................................... ...... -··--.._ ....... _ ........... ~-,... ,_ &..-~ .... ...,,. ..... ._._ .... _ ............ - - -._ ---- - ______ .... __ c.,. ___ ...,..., ___ .....,-..,_""" ____ .. ....._ __ ........... __ . .,,. ....... ~ .. ________ .. ... , ___ _,_ .. __ .... _.,. _____ .. __ .... ____ ,.__ ----·---·-~ --~------·-... ----..----·--...u-.----_..,. ............ 0...:..--..._..... ....................... c..... .. ......... -~ .... -

..

•

PROFILE BANK

To Profile Bank:

I gr.me permission for Profile Bank to release the following mform:ition into my cuscody abouttnyaccount~

To whom it may concern: As of June 24, 2015 the above referenced account hns a bnlancc of 103,222.35. If you have aoy questions please feel free to contact me at (603)875-4100 xl02

Bank Repres

Date: June 24, 2015

NMLS# 412728

ROCHESTER • SANBORNVILLE • ALTON• SOMERSWORTH

Main Office: 45 Wak11f\eld Street, PO Bo>e. 1606, Roche&ter, NH 03866-ieoa • Phom1~ (603) 332.-2.610 Fax: (603) 332-2519

www.ProfileBanlc.com

~ Cambridge E• Retirement Board

·---·----

Records Reported On: 20

Annuity Savings Detail Innocent E Lugumamu

Olll22/201511:37:41 Page:1

User: EllenPhllbln

Total

tntereat Rate Pets: 2015: 0.1; 2014: 0.1; 2013: 0.1; 2012: 0.1; 2011: 0.2; 2010: 0.3; 2009: 0.5; 2008: 0.6; 2.007: 0.6; 2006: 0.6; 2005: 0.6: 2004: 0.6; 2003: 1.0: 2002: 1.4: 2001: 1.9; 2000: 2.1: 1999: 2.2; 1998: 2.4: 1997: 2.5; 1996: 2..5: 1995: 2.6; 1994: 2.5: 1993: 3.1; 1992: 4.7; 1991: 5.4; 1990: 5.4; 1~9: 5.3; 1986: 5.2; 1987: 5.5; 1986: 5.5; 1985: 5.5; 1984: 5.5; 1983: 9.5; 1962: 8.4; 1981: 7.2; 1980: 6.7; 1979: 6.4; ..

Memo Text: TACS Data Load Info: AclMty Code:PA-Actlve member at beginning of year

NORTHMARK9 BANK

June 26, 2015

To Whom It May Concern:

This Is written to verify that there are two checking accounts in this Bank operated b The titles and balances In these accounts are as follows:

ACN II Account: $257,202.53

Centre Realty Trust $167,133.47

~~cUJ~ Maureen C. Pollard Branch Manager

89 Turnpike Street P.O. Box 825 North Andover, MA 01845 (978) 686-9100 FAX (978) 686-5779 Andover Office 69 Park Street Andover, MA 01810 (978) 475-5000 PAX (978) 749-7000

Winchester Office 26 Mount Vernon Street Wmchester, MA 01890 (781) 721-9100 FAX (781) 721-9948 www.northmarkbank.com

Account Assets - -

Assets I Profile I Transactions I Executions I Transfers I Customer ID I Related I Documents

Account Assets View account positions, generate reports, or go to a selected activity for the account. You can also link to security, transaction, and tax lot det:Blls for a listed position.

Search Results

Reps Included: All Reps

Oosed Accounts: Not Included

Today's Activity: Not Included

I.Pl. Account Number: (starts With) -

Reports s. Graphs: I-Select A Report -:==vJ a Account - Summary As Of 06/25/2015 Account:

Account Cass: Investment Obj:

SSN{Tax ID:

Rep:

Home Phone: Buslness PhOne:

MOblle Pnone:

Email Address:

Open Notillcatlons:

B&R Status:

SultablHty Status:

(IOXB) ROBERT PAUL

(617) 966-8330

None

~ Comp

Groups: CARUSO ANOOEA530ol97l8 {CUentl

= Account· Balances As Of 06/25/2015 Total Account Value at LPL:

Cash and Equlvelent Pct:

185,453.76

4.05 'lb

5el~~ Account Class:

I- All Account Classes - vi LPL Account Nwnber:

Account Name: SSN/Tax IO:

I II I 0 Existing D Outgoing D Incoming

Accounts Transfers Transfers

Search 1'4 New Search jQ,. Export I~ Clear lo Search Tips I?

Vlaw: I Assets -3

Account Registration: PTC CUST ROLLOVER IRA FBO ANDREA CARUSO

Holder Birth Date:

. lculated Age:

Account Nickname: ~

Go To: Fselect an Activity - v I Total Account Value at LPL: 185,453.76

Total Account Value Including Outside Investments: 185,453.76

Pagel of 3 Caruso, 1 of 7

httns://hmnchnet.lnl.cnm/ A 'R/J .Pr .IT .PT .netail.asnx?loc=f .Pr .&lnlaccr-71430115&ea=Y &ota=N&ita=N&accountlD=&ssrbvs t... 612612015

~

Account Assets -

Assets I Profile I Transactions I Executions I Transfers I Customer JD I Related I Documents

Account Assets View account positions, generate reports, or go to a selected activity for the account. You can also llnk to security, transaction, and tax lot details for a listed position.

Search Results

Reps lnduded: All Reps

Closed Aceoonts: Not lnciuded

Today's Activity: Not lnciuded

LPL Account Number: (starts with) -

Reports & Graphs: I - Select A Report - VJ

1:1 Account - Summitry As Of 06/25/2015 Account: Account Oass: Investment Obj:

SSN/Tax ID:

Rep: Home Phone:

Business Phone:

Moblle Phone: Email Address:

Open Notmcatlons: B&.R Status:

Sultablllty Status:

(1DXB) ROBERT PAUL -(617) 966-8330 None

~

~

Groups: ~

1:1 Account - Balances As Of 06/25/2015 Total Account Value at LPL: Cash and Equivalent Pct:

116,841.96

0.33%

Select Account Class:

I- An Account Classes - vi ber:

Account Name: SSN/Tax ID:

I II I 0 Existing 0 Outgoing 0 Incoming

Accounts Transf'" Transfers

I Search l Q,. I New Search l~ I Export Iii:> lc1ear le I Search rps 11

View: I Assets --- VJ

Account Registration: ANDREA COSTA CARUSO AND RALPH CARUSO TTCfS ANDREA COSTA CARUSO REV TRUST OTO 12·07·11

- te:

~lated Age:

Account Nickname:

~

Go To: I- Select an Activity - v I Total Account Value at LPL: 116,841.96

Tot!ll Account Value Including Outside Investments: 116,841.96

Page 1 of2

Caruso, 2 of 7

https://branchnet.lpl.com/ AB/LPL/LPLDetail.aspx?loc=LPL&lplacct-18833018&ea=Y &ola=N&ita=N&accountID=&ssrbvs _ t... 6/26/2015

Account Assets


Account Assets View account positions, generate reports, or go to a selected activity for the account. You can also link to security, transaction, and tax lot details for a listed position.

Search Results

Reps Included: All Reps

Closed Accounts: Not lnduded

Today's AcUvlty: Not lnduded

LPL Account Number: (starts with}-

Reports a G1'3phs: I- Select A Report - v I

1:1 Account· Summary As Of 06/25/2015 Account:

Account Oass:

Investment Obj:

SSNJTax fD: Rep: Home Phone:

Business Phone:

MDblle Pticme: Email Address: Open Notifications:

B&R Status: SultablUty St

Account Assets --


Account Assets View account positions, generate reports, or go to a selected activity for the account. You can also link to security, transaction, and tox lot details for a listed position.

Search Results

Reps Included: All Reps Closed Accounts: Not Included Today's Activity: Not Included


Reports a Graphs: [=Select A Report---::VJ

a Account - summary As Of 06/25/2015 Account:

Account aess:

Investment Obj:

SSN/Tax ID:

Rep:

Home Phooe:

BuslneH Phone:

Moblle Phone: Email Address: Open Notlflcatlons:

B&Jt Status: Suitability Status:

--l (781) 284·4260

None

~ Comp

Groups: CARt,JS_O AALPl-I iea6101_0_LC!ientl

= Account - Balances As Of 06/25/2015 Total Account Value at lPI..: Cash and Equivalent Pct:

31,562 .. 99

3.15 %

Select Account Class: (SWCh I~ I New Search I~ l I- All Account Classes - vi

LPL Account Num=b-"'er;.;.: _____ ~ Export !$> I Clear IC: I Search Tips I ? I

Account Name: SSN/Tal( ID:

I 11 I

~ ExlstJnu Ooutgoinu D Incoming Accounts Transfers Transfers

View: I Assets VI

Go To: I - Select an Activity - v I:

Account Reorstratlon: Total Account Value at LPL: RALPH CARUSO AND ANDREA COSTA CARUSO mes RALPH CARUSO REVOCABLE TRUST I II I

- ate:

.-ulated Age:

Account Nickname: ··save--

Tob!I Account Value Including OUtslde Investments: 31,562.99

Pagel of3

Caruso4 of7

httns://hranchnet. Int .com/ A BILPL/LPLDetail.asox?loc=LPL&lolacct=5 7777896&ea= Y &ota=N&ita-2N&accountlD=&ssrbvs t... 6/26/2015

Account Assets - 39537563


Account Assets View account positions, generate reports, or go to a selected activity for the account You can also link to security, transaction, and tax lot details for a listed position.

Search Results

Reps lnduded: All Reps aosed Actounts: Not lnduded

Today's Activity: Not lnduded


Reports • Graphs: I - Select A Report - v I

a Account - Summary As Of 06/25/2015 Account:

Account aass:

Investment Obj:

SSN(fax ID: Rep:

Home Phone: Business Phone:

Moblle Phone: Emall Address: Open Nottncatlons: BM Status: Sultablllty Status:

(10XB) ROBERT PAUL

(617) 966·8330

None

~

fWI

Groups: CARUSO ANDREA 53-049718 !Olentl

a Account- Balances As Of 06/25/2015 Total Account Valu~ at LPL: cash and Equivalent Pd:

0.00

0.00 'lb

Select Account Cass:

I-All Account Classes - vi LPL Account Nu;:.:.:m.:::be:.:..:r: ____ _

Account Name: SSN/Tex ID:

I 11 I

~ Existing D outgoing 0 Incoming Accounts Transfers Transfers

Search I~

New Search I~

Export Ii!:> Clear le Search rips I?

View: I Assets \II

Account Registration: ANDREA CARUSO IRA· IVA FUNDS OUTSIDE INVESTMENTS. RETIREMENT

Holder Birth Date:

.. dAge:

Account Nickname: --save--

Go To: I - Select an AcliVJtY= . v I Total Aa:ount Value at LPL: 0.00

Total Account Value lndudlng Outside lnvesbnents: 19,758.37

Page 1of2 Caruso, 5 of 7

httm: · / /hrnn~hnP.t lnl r.nm/ A R/T .PT .IT. PT .Oetni l.ac::nx?lnc=f. PT .&lnlacct=3953 7 563 &ea= Y &ota=N&ita=N&accountlD=&ssrbvs t... 6/26/2015

Account Assets


Account Assets View account positions, generate reports, or go to a selected activity for the account. You am also link to security, transaction, and tax lot details for a listed position.

Search Results

Reps lnduded: All Reps

Closed Acaiunts: Not Included Today's Activity: Not lnduded

LPL Account Number: (starts with-

Reports & Graphs: I - Select A Report - v I

1:1 Account- Summary As Of 06/25/2015 Account:

Account Class:

Investment Obj:

SSN/Tax ID: Rep: Home Phone: Buslness Phone: Mobile Phone:

Email Address: Open Notlfttallons:

B&R status: SultabUlty Status:

None

Q2mJ2

~

Groups: CARUSO ANDREA S~lHU_Cllentl

= Account - Balances As Of 06/25/2015 Total Account Value at LPL:

Cash and Equivalent Pct: o.oo 0.00 %

Select Account Class:

I- All Account Classes - VJ LPL Account Number: -;..;;.;..;.....-~! Aca>unt Name: SSN/TaJC ID:

I 11 I

~ Exlstlno 0 Outgoing 0 Incoming Accounts Transfers Transters

I Seardl IO:. I INewSearch 1'41 I export I~ I lc~ar le I I Search lips I "1 I

View: I Assets - v I

Account Registration: ANDREA CARUSO IRA OUTSIDE INVESTMENTS· ... Holder Birth Date:

lliliilllated Age:

Account Nld«lame: ~

Go To: I - Select an Activity _:_---v I

Total Account Value lndudlng Outside Investments: 17,573.59

Page 1 of2

Caruso, 6 of 7

httns://branchnetlol.com/ AB/LPL/LPLDetail.asox?loc=LPL&loJacct=48413214&ea=Y &ota=N&ita=N&accountID=&ssrbvs t... 6/26/2015

Account Assets


Account Assets View account positions, generate reports, or go to a selected activity for the account. You can also link to security, transaction, and tax lot details for a listed position.

Search Results

Reps lnduded: AU Reps

Clo,ed Accounts: Not Included Today's Activity: Not lnduded

LPL Account Number: (starts with)

Reports ll Graphss I-Select A Report - v I

= Account - Summary As Of 06/25/2015 Account: Account aass: Investment Obj: SSN/Tax ID:

Rep:

Home Phone: Business Phone: Mobile Phone: Email Address:

Open Notlficatlons:

B&R Status: Suitability Status:

(1DX8) R06~T PAUL

(617) 966·8330

None ~ ~

Groups: ~RU£0_AN~EA 53049718 (Client)

m Account - Balances As Of 06/25/2015 Total Account Value at LPL:

Cash and Equivalent Pct: o.oo 0.00 "lo

Selt!d: Account Oass:

I-· All Account ciasses - vi 1-.. a -- - "'-"'' ·--L- ...

~Existing Ooutgolno 01ncom1no Accounts Transfer.; Transfers

!Search I~ I New Search le\ I Export le:> jc1ear le I Search Tips 11

view: [A!seis -~ 3

Account Registration: ANDREA CARUSO ROTH IRA· !VA FUNDS OUTSIDE INVESTMENTS· RETIREMENT

Ho]der Birth Date:

~ulatedAge:

Account Nickname: ~

Go To: I~ seteetan Activity- vi Total Account Value at LPL: o.oo

Tot.al Account Value lndudlno Outside Jnvatments: 3,214.13

Page I of2

Caruso, 7 of 7

httnc:·/fhr~nrhnPt lnl r.nm/ A 'R/T .PT .IT .PT .OP.h1il.sisnx?loc=l .Pl ,&lnlacct=69844600&ea=Y &ota=N&ita=N&accountlD=&ssrbvs t... 6/26/2015

Fidelity. C U!:;l Cli.IFH 5EIWICF. 1 OP!;~l NJ .,ct:Ot.;tH 1 f.\!:1-t.R A H~lUW , LU Ci ou I Accounts & 1rm1e News&. Insights ResearU1

Vour Proftlo >

Personal Information/Address P.,..onal Jnfonnatla n

N;ame "'-'Y CHAN HUI

~te or Birth -Prim:ory E-M.lll! Addi-ess HUISSOIVERJZON.NET

Optlanol E-Mall Addresc:

Country of Citl:r.ensh!p UNITED STATES

Hclp/Gtguacv

Updall!

Update

Update

Penono!Addresa/Phono Wnat is Personal Actelress/PhOl\C?

Malling Address

Legal/Residential Address

Phone Numbers

SCNonol Addn:sa (Temponiry MDl!!ng Addrcsa)

UP

Commitment Letter

June 27, 2015

This commitment letter is intended to set forth the genera) loan parameters, as agreed to by the Borrower, the CAS Foundation a Commonwealth of Massachusetts Non·Profit Corporation and the Lender, as defined below, as they relate to the financing of the CAS Foundation in its efforts to establish a "Registered Marijuana Dispensary" (RMD) and/or "Dispensaries" under l 05 CMR 725.000: IMPLEMENTATION OF AN ACT FOR THE HUMANITARIAN MEDICAL USE OF MARIJUANA. The following sets forth the terms and conditions upon which the Lender will make the loan to the CAS Foundation.

Lender; Borrower; Guarantors;

Loan Amount;

Loan Tenn;

Contingencies;

CAS Foundation .:. e I t • on

Personally

Up to a maximum of $260,000.00 for the purpose of establishing and operating a "Registered Marijuana Dispensary or Dispensaries".

A Five (5) year, unsecured, loan at an interest rate of TEN percent (J 0%).

The Lender shall have no obligation to commit any funds to CAS Foundation until;

The Entity has secured the licenses, pennits and approvals to establish and operate a "Registered Marijuana Dispensary or Dispensaries in the Commonwealth of Massachusetts, in accordance and compliance with the laws of the Commonwealth of Massachusetts.

We, the undersigned, het"eby agree to the above terms and conditions of this commitment Letter.

C11rdill(: Arrhythmia Syndromes Foundation, Inc. · • . 2 of_3 _ . . nka • CAS Foundation

Application _ Applicant Non-Profit Corporation - --------------

ATTESTATIONS

Signed under the pains and penalties of perjury, I, the authorized signatory for the applicant non~profit corporation, agree and attest that all information included in this application is complete and accurate and that J have an ongoing obligation to submit updated information to the Department if the infonnation

• · · · · has changed.

Print Name of Authorized Signatory

CEO & Prcsidcnl

Title of Authorized Signatory

06/22/2015

Date Signed

I hereby attest that if the non-profit corporation is allowed to proceed to submit a Management and Operations Pro.file, the applicant non-profit corporation is prepared to pay a non-refundable application fee of$30,000 and the cost of all required background checks, and comply with all Management and 0 era/ions Pro quirements.


CEO & President


06/26/2015

Date Signed

J hereby attest that I understand that registered marijuana dispensaries are required to conduct background investigations of proposed Dispensary Agents, that such background investigations are subject to the Department's Inspection and review, and that the applicant non-profit corporation wiJI not engage the services of a Dispensary Agent that has ever been convicted of a felony drug offense in Massachusetts, or a like violation of the laws of another slate, the United States, or a military, territorial, or Indian tribal


CEO & President


06/2212015

Date Signed

lnfonnation on this page has been reviewed by the app~1ere provided by the applicant, is accurate and complete, as indicated by the initials of the authorized signatory he • .__


#2of3

~e-