ohio medical marijuana dispensary application elevate 1803 ...€¦ · stockmeister 16064 beaver...
TRANSCRIPT
Ohio Medical Marijuana Dispensary Application
ELEVATE 1803 LLC Application ID 947
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
Elevate 1803 LLC
None
16064 Beaver Pike
Jackson
OH
45640
7403951286
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
Seth
Alan
Stockmeister
16064 Beaver Pike
Jackson
OH
45640
7403951286
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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
Limited Liability Company
No response provided by applicant
OH
09/21/2017
Elevate 1803 LLC
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
No response provided by applicant
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-5
Fairfield
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
David
Leroy
Johns
N/A
Retired Senior Vice President & Chief Information Officer of Retail Sales and ManufacturingCompanies
CEO/CIO
$0
N/A
Membership Interest
7.31%
7.31%
OWNER
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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 Tax
Contribution of $11,300; Business Expertise
This response has been entirely redacted
This response has been entirely redacted
4772 Shire Ridge Rd E
Hilliard
OH
43026
4194509159
No response provided by applicant
59 years; Since Birth 1958
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 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
Kenneth
Neil
Triplett
N/A
Retired Owner of Importing Warehousing and Wholesale Distribution Company
Supply Chain Advisor
$0
N/A
Membership Interest
7.31%
7.31%
OWNER
Contribution of $11,300; Business Expertise
--
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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
1109 Bronx Corner Road
Ray
OH
45672
7406490888
No response provided by applicant
65 years; Since Birth 1952
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 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
Kevin
Lynn
Lykens
N/A
Owner of Lykens Companies, Real Estate Development
Chief Financial Officer
$0
N/A
Membership Interest
14.61%
14.61%
OWNER
Contribution of $22,600; Real Estate/Business Expertise
--
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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
994 Dennison Ave
Columbus
OH
43201
6145654209
No response provided by applicant
44 years; Since Birth 1973
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 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
Michael
Wesley
Redd
N/A
Former NBA Basketball Player, Entrepreneurial Investor
Community Relations, Outreach, Social Media & Marketing Advisor
$0
N/A
Membership Interest
14.61%
14.61%
OWNER
Contribution of $22,600; Community Relations/Business Expertise
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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
2 Crescent Pond
New Albany
OH
43054
6145120592
No response provided by applicant
38 years; Since Birth 1979
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 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
Charles
Mitchell
Fields
N/A
Retired Orthopedic Surgeon and Owner of Ohio Valley Sports Medicine
Clinical/Medical Director
$0
N/A
Membership Interest
7.31%
7.31%
OWNER
Contribution of $11,300; Business/Medical Medicine and Pain Management Expertise
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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
6759 St Rt 159
Chillicothe
OH
45601
7407037781
No response provided by applicant
62 years; Since Birth 1955
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
Robert
Allen
Munn
N/A
Retired Owner of Multiple McDonalds Franchises
Retail Sales Director
$0
N/A
Membership Interest
7.31%
7.31%
OWNER
Contribution of $11,300; Business Expertise
--
-
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
210 Redondo Drive
Jackson
OH
45640
7402865130
No response provided by applicant
69 years; Since Birth 1948
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 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
Ryan
Kelly
Wright
N/A
Vice President of Engineering at Bellisio Foods
Engineering & Process Director
$0
N/A
Membership Interest
7.31%
7.31%
OWNER
Contribution of $11,300; Business/Engineering Expertise
--
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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
12 Pleasant View Drive
Jackson
OH
45640
7404187960
No response provided by applicant
23 years; 1994
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 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
Seth
Alan
Stockmeister
N/A
Owner of Construction Companies
General Manager/Security Director
$0
N/A
Membership Interest
14.61%
14.61%
OWNER
Contribution of $22,600; Business Expertise
--
-
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
5707 Franklin Valley Rd
Jackson
OH
45640
7403951286
No response provided by applicant
36 years; Since Birth 1981
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 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
Walter
Edwin
Dennis
Jr.
Owner of HFI, a Tier 2 Automotive Supplier
Brand Ambassador & Advisor
$0
N/A
Membership Interest
7.31%
7.31%
OWNER
Contribution of $11,300; Business Expertise
--
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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
3410 River Rhone Ln
Columbus
OH
43321
6143954842
No response provided by applicant
66 years; Since Birth 1951
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 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
Michael
James
Shawd
N/A
Owner of Goddard-Shawd Insurance Agency
Insurance, Surety, & Financial Advisor
$0
N/A
Membership Interest
7.31%
7.31%
OWNER
Contribution of $11,300; Business Expertise
--
-
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
P.O. Box 163
Barlow
OH
45712
7405254174
No response provided by applicant
62 years; Since Birth 1955
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 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
Natalie
Jane
Ring
N/A
Clinical Pharmacist
Patient Advocate and Pharmaceutical Advisor
$0
N/A
N/A
0%
0%
PERSON EXERCISING SUBSTANTIAL CONTROL
Compounding/Pharmaceutical Expertise
--
-
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
5318 Casper Dr.
Charlotte
NC
28214
5134601880
No response provided by applicant
Not an Ohio Resident
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 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
Rodney
Barry
Stout
N/A
Chief Medical Officer/Medical Director of Research/Endocrinologist
Patient Advocate and Medical Advisor
$0
N/A
N/A
0%
0%
PERSON EXERCISING SUBSTANTIAL CONTROL
Medical Expertise
--
-
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
Burnheimer Rd
Gallipolis
OH
45631
7407091483
No response provided by applicant
22 years, 1995-present
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
Alan
Arthur
Stockmeister
N/A
Entrepreneur
Governmental Affairs Advisor
$0
N/A
N/A
0%
0%
PERSON EXERCISING SUBSTANTIAL CONTROL
Business Expertise
--
-
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
213 Redondo Dr.
Jackson
OH
45640
7404184129
No response provided by applicant
Since Birth; 1952 - Present
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
Kay
Ann
Howe
N/A
Accountant
Controller/Administration Director
$0
N/A
N/A
0%
0%
PERSON EXERCISING SUBSTANTIAL CONTROL
Business/Accounting Expertise
--
-
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 Redondo Dr.
Jackson
OH
45640
7404185250
No response provided by applicant
23 Years; 1994-Present
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
Benjamin
Charles
Jones
N/A
Regional Sales & Marketing Manager (Plan C Life, Inc d/b/a Lola Lola, Southern California)
Dispensary Compliance Control Manager
$0
N/A
N/A
0%
0%
PERSON EXERCISING SUBSTANTIAL CONTROL
Medical Marijuana Sales and Marketing Expertise
--
-
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
629 Westmount Dr. Apt 2
W Hollywood
CA
90069
7408043140
No response provided by applicant
Not an Ohio Resident
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
Dieneka
None
Manzanares
N/A
Co-founder & CEO of Sweet Leaf Pioneer
Quality Assurance Director
$5,000.00 One Time Fee + $5,000 success fee per location, capped at $15,000
N/A
N/A
0%
0%
PERSON EXERCISING SUBSTANTIAL CONTROL
Medical Marijuana Dispensary Operations Expertise
--
-
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
0419 Washington St
Eagle
CO
81631
9703766248
No response provided by applicant
Not an Ohio Resident
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
Joseph
Max
Cohen
N/A
Founder & CEO - The Clinic
Chief Operating Officer
$0
N/A
N/A
0%
0%
OFFICER
Medical Marijuana Industry Expertise
--
-
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
2330 E. Louisiana Ave
Denver
CO
80210
7206396718
No response provided by applicant
Not an Ohio Resident
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 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
Emily
Rachel
Cohen
N/A
Director of Business Development at The Clinic
Chief Compliance Officer
5% Equity + $5,000 success fee per location, capped at $15,000
N/A
Membership Interest
5.00%
5.00%
OWNER
Expertise in dispensary operations and compliance
--
-
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
414 Harrison Street
Denver
CO
80206
7206396720
No response provided by applicant
Not an Ohio Resident
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
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
No response provided by applicant
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 of
David
Leroy
Johns
OWNER
CEO/CIO
Ensures directives are met, oversees policies and facilitates adoption of regulations, technical vision,facilitates compliance and all other systems: security, inventory and surveillance, etc.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
NO
No response provided by applicant
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 of
Kenneth
Neil
Triplett
OWNER
Supply Chain Advisor
Supply chain management including efficient product inventory, logistics, and returns, and best productpricing discovery.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
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 of
Kevin
Lynn
Lykens
OWNER
Chief Financial Officer
Accountable for administrative, financial, and risk management functions and systems. This positionguarantees accuracy of financial reporting, internal accounting controls and compliance.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
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 of
Michael
Wesley
Redd
OWNER
Community Relations, Outreach, Social Media & Marketing Advisor
Delivery of high-quality, engaging multi-channel Internet content and creation of community outreachinitiatives while building additional community members.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
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 the
Michael
James
Shawd
OWNER
Insurance, Surety, & Financial Advisor
Providing expert guidance on finance, insurance, underwriting and surety solutions.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
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 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 of
Charles
Mitchell
Fields
OWNER
Clinical/Medical Director
Owns patient care; medical staff conduct; developing and delivering training for local physicians, andprocess improvement.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
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 the
Robert
Allen
Munn
OWNER
Retail Sales Director
Sales facilitation to drive sustainable growth and product guidance.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
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 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 of
Ryan
Kelly
Wright
OWNER
Engineering & Process Director
Designing, implementing, and improving dispensary processes for higher product quality at lowercosts.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
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 in
Seth
Alan
Stockmeister
OWNER
General Manager/Security Director
Oversees all operations and director-level employees, communicates processes, quality assuranceincluding record keeping, security, safety. Plan and monitor implementation of security systems; hire,train, and supervise new security employees.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
lieu 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.
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.
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 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?
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
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 response provided by applicant
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 of
Walter
Edwin
Dennis
OWNER
Brand Ambassador & Advisor
Execution of sustainable, measurable brand strategy and increasing brand awareness and productsales.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
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.
Natalie
Jane
Ring
PERSON EXERCISING SUBSTANTIAL CONTROL
Patient Advocate and Pharmaceutical Advisor
Guidance on, and create of, a comfortable, acceptable, and accessible experience for registeredpatients.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
NO
No response provided by applicant
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 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.
Rodney
Barry
Stout
PERSON EXERCISING SUBSTANTIAL CONTROL
Patient Advocate and Medical Advisor
Patient and employee guidance on product treatment options.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
NO
No response provided by applicant
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 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.
Alan
Arthur
Stockmeister
PERSON EXERCISING SUBSTANTIAL CONTROL
Governmental Affairs Advisor
Maintenance of critical local and state communities relationships, local organization partnershipidentification, legislation change monitoring, and management team reporting of findings.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
NO
No response provided by applicant
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 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.
Kay
Ann
Howe
PERSON EXERCISING SUBSTANTIAL CONTROL
Controller/Administration Director
Focuses on financial statement preparation, general ledger, reconciliations, cash management, fixedasset accounting, and payroll. She has oversight of inventory, variances, impairment and discards.
YES
Appalachian Pharm Products, LLCAppalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
NO
No response provided by applicant
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 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.
Benjamin
Charles
Jones
PERSON EXERCISING SUBSTANTIAL CONTROL
Dispensary Compliance Control Manager
Establishment of compliance requirements and product quality controls for the dispensary.
YES
Appalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640
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
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 of
Dieneka
None
Manzanares
PERSON EXERCISING SUBSTANTIAL CONTROL
Quality Assurance Director
Accountability, application, and regulatory agency interfacing for dispensary compliance; staffcommunication; SOP and inspection evaluation; metrics alignment; oversight of employees andpackaging/labeling materials; dispensary safety and cleanliness; monitoring of safes, vaults, andsecurity area authorization.
YES
Sweet Leaf Pioneer, LLC1286 Chambers Ave # 105 & #101, Eagle, CO 81631
YES
Sweet Leaf Pioneer, LLC1286 Chambers Ave # 105 & #101, Eagle, CO 81631
whether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent 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 Drug
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
Enforcement 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?
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
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 response provided by applicant
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.
Joseph
Max
Cohen
OFFICER
Chief Operating Officer
Oversight of dispensary operations (compliance, staffing, quality assurance, inventory tracking, patientcare)
YES
Appalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, OH 456404625 East Colfax, LLC (The Clinic on Colfax)4625 E. Colfax Ave. Denver, CO 802204625 East Colfax, LLC (The Clinic on Colfax)5098 N Paris St Building 1, Unit 1, Denver CO. 80239Compassionate Enterprises, LLC (The Clinic on Jewell)1127 W 46th Ave. Denver, CO 80211Compassionate Enterprises, LLC (The Clinic on Jewell)12018 W. Jewell Ave Unit C, Lakewood, CO. 80228Compassionate Enterprises, LLC (The Clinic on Wadsworth)1127 W 46th Ave. Denver, CO 80211Compassionate Enterprises, LLC (The Clinic on Wadsworth)3600 S Wadsworth Blvd, Units D, Lakewood, CO 80235Compassionate Enterprises, LLC (The Clinic on Wadsworth)3600 S Wadsworth Blvd, Units D&E, Lakewood, CO 80235Compassionate Enterprises, LLC (The Clinic on Wadsworth)5098 N Paris St Building #1, Unit 1, Denver CO. 80239
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.
Compassionate Enterprises, LLC (The Clinic on Wadsworth)5098 Paris St Building #1, Unit 1, Denver CO. 80239Fiorello Pharmaceuticals, Inc12 E 49th St. 11th Floor, New York, NY 10017GTI Oglesby, LLC110 E 4th St. Oglesby, IL 61348GTI Rock Island, LLC8221 W 51st St. W Rock Island, IL 61201Highlands Wellness Center, LLC (The Clinic Highlands)2020 S Colorado Blvd. Denver CO. 80222Highlands Wellness Center, LLC (The Clinic Highlands)2675 Santa Fe Dr. Units 6D, 6E, 6F, 6G, and 6H Denver, CO 80223Highlands Wellness Center, LLC (The Clinic Highlands)3460 W 32nd Ave. Denver CO. 80211Highlands Wellness Center, LLC (The Clinic Highlands)5098 N Paris St Building 1, Unit 1, Denver CO. 80239Holly Medicinal Services, LLC (The Clinic on Colorado)1127 W 46th Ave. Denver, CO 80211Holly Medicinal Services, LLC (The Clinic on Colorado)2020 S Colorado Blvd. Denver CO. 80222Holly Medicinal Services, LLC (The Clinic on Colorado)2675 Santa Fe Dr. Units 6D, 6E, 6F, 6G, and 6H Denver, CO 80223Innovation Labs, LLC12 Broadway #220, Denver CO. 80209Innovation Labs, LLC (Telluride)5098 N Paris St Building 2, Unit 1, Denver CO. 80239The Clinic Mundelein1325 Armour Blvd, Mundelein, IL 60060Zuni Wellness Center, LLC (The Lab)2675 Santa Fe Dr. Unit 6C Denver, CO 80223Zuni Wellness Center, LLC (The Lab)2675 Santa Fe Dr. Units 6D, 6E, 6F, 6G, and 6H Denver, CO 80223Zuni Wellness Center, LLC (The Lab)5098 N Paris St Building 2, Unit 1, Denver CO. 80239
YES
4625 East Colfax, LLC (The Clinic on Colfax)4625 E. Colfax Ave. Denver, CO 802204625 East Colfax, LLC (The Clinic on Colfax)5098 N Paris St Building 1, Unit 1, Denver CO. 80239Compassionate Enterprises, LLC (The Clinic on Jewell)1127 W 46th Ave. Denver, CO 80211Compassionate Enterprises, LLC (The Clinic on Jewell)12018 W. Jewell Ave Unit C, Lakewood, CO. 80228Compassionate Enterprises, LLC (The Clinic on Wadsworth)
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.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,
1127 W 46th Ave. Denver, CO 80211Compassionate Enterprises, LLC (The Clinic on Wadsworth)3600 S Wadsworth Blvd, Units D, Lakewood, CO 80235Compassionate Enterprises, LLC (The Clinic on Wadsworth)3600 S Wadsworth Blvd, Units D&E, Lakewood, CO 80235Compassionate Enterprises, LLC (The Clinic on Wadsworth)5098 N Paris St Building #1, Unit 1, Denver CO. 80239Compassionate Enterprises, LLC (The Clinic on Wadsworth)5098 Paris St Building #1, Unit 1, Denver CO. 80239Fiorello Pharmaceuticals, Inc12 E 49th St. 11th Floor, New York, NY 10017GTI Oglesby, LLC110 E 4th St. Oglesby, IL 61348GTI Rock Island, LLC8221 W 51st St. W Rock Island, IL 61201Highlands Wellness Center, LLC (The Clinic Highlands)2020 S Colorado Blvd. Denver CO. 80222Highlands Wellness Center, LLC (The Clinic Highlands)2675 Santa Fe Dr. Units 6D, 6E, 6F, 6G, and 6H Denver, CO 80223Highlands Wellness Center, LLC (The Clinic Highlands)3460 W 32nd Ave. Denver CO. 80211Highlands Wellness Center, LLC (The Clinic Highlands)5098 N Paris St Building 1, Unit 1, Denver CO. 80239Holly Medicinal Services, LLC (The Clinic on Colorado)1127 W 46th Ave. Denver, CO 80211Holly Medicinal Services, LLC (The Clinic on Colorado)2020 S Colorado Blvd. Denver CO. 80222Holly Medicinal Services, LLC (The Clinic on Colorado)2675 Santa Fe Dr. Units 6D, 6E, 6F, 6G, and 6H Denver, CO 80223Innovation Labs, LLC12 Broadway #220, Denver CO. 80209Innovation Labs, LLC (Telluride)5098 N Paris St Building 2, Unit 1, Denver CO. 80239The Clinic Mundelein1325 Armour Blvd, Mundelein, IL 60060Zuni Wellness Center, LLC (The Lab)2675 Santa Fe Dr. Unit 6C Denver, CO 80223Zuni Wellness Center, LLC (The Lab)2675 Santa Fe Dr. Units 6D, 6E, 6F, 6G, and 6H Denver, CO 80223Zuni Wellness Center, LLC (The Lab)5098 N Paris St Building 2, Unit 1, Denver CO. 80239
NO
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?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
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-3.15 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
NO
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 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.
Emily
Rachel
Cohen
OWNER
Chief Compliance Officer
Oversight and management of all compliance issues
YES
Appalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640GTI Oglesby, LLC110 E 4th St. Oglesby, IL 61348GTI Rock Island, LLC8221 W 51st St. W Rock Island, IL 61201The Clinic Mundelein1325 Armour Blvd, Mundelein, IL 60060
YES
Appalachian Pharm Processing, LLC16064 Beaver Pike, Jackson, Ohio 45640GTI Oglesby, LLC
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.
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
110 E 4th St. Oglesby, IL 61348GTI Rock Island, LLC8221 W 51st St. W Rock Island, IL 61201The Clinic Mundelein1325 Armour Blvd, Mundelein, IL 60060
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-3.13 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?
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.
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
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?
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 response provided by applicant
NO
No response provided by applicant
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_Property Title, Lease, or Option to Acquire Property Location -Greenfield Twp Fairfield County.pdfNOTE: This applicant uploaded document is the next 15 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
Elevate 1803, LLC
N/A
1402 Ety Rd
Greenfield Township, Fairfield County
OH
43130
7403951286
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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_Renovation Plans and Specifications Interior and Exterior -Greenfield Township.pdfNOTE: This applicant uploaded document is the next 6 page(s) of this document.
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_Notice of Proper Zoning - Greenfield Twp Fairfield County.pdfNOTE: This applicant uploaded document is the next 4 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_Location Area Radius Map - Greenfield Twp FairfieldCounty.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
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. TRADE SECRETProspective Associated Key Employees (PAKEs) will oversee Elevate 1803’s dispensary forcompliance with the Board of Pharmacy (BoP) and Medical Marijuana Control Program (MMCP).PAKEs provided proof of eligibility/fingerprints to the Ohio Bureau of Criminal Identification andInvestigation and FBI for a criminal records check, and will always hold MMCP I.D. cards while ondispensary property.
CEO/CIO (David Johns): Executive leadership to meet company goals within timelines/budgets, policychanges, BoP compliance, and company performance; value creation through technology andprocedures that lead to business goals. Qualifications: 18 years C-level management experience atbillion-dollar global companies; responsible for 1000+ employees across 4 continents. Managedoperations, technology and shared services organizations. Accomplishments: MBA in Finance and BSin Computer Science Engineering, Board Member of several Ohio companies, member of CIO Hall ofFame.
General Manager/Security Director (Seth Stockmeister): Plans/monitors security systems; hires, trains,and supervises employees. Qualifications: 10 years in director-level position, BoP and MMCPknowledge, record keeping, and bachelor’s degree. Secured $200 million annual inventory usingdigital/analog security measures and 16 armed/unarmed guards in a Department of Homeland Securityfacility.
Chief Operating Officer (Max Cohen): Oversight of dispensary operations (compliance, staffing, qualityassurance, inventory tracking, patient care); employees/process communication guidance ; qualityassurance accountability for record keeping, patient confidentiality, security, IT, human resources, andproduct consistency/safety; financial document drafting/review, and efficiency. Max’s past experienceas an industry entrepreneur, success, and policy maker will add to the dispensary’s success andcompliance in the future.
Chief Financial Officer (Kevin Lykens): Accountability for administrative, financial, risk management,and operational strategy development metrics and accurate financial reporting. Qualifications: 10 yearsexecutive level experience, high-level communication ability, CPA; accounting principles,procedures/administration knowledge.
Chief Compliance Officer (Emily Cohen): Oversight and management of all compliance issues, theQuality Assurance Director, and all employees; ensuring that the dispensary is in line with allcompliance regulations from the BoP and the MMCP; maintaining, developing, and implementingaccountability, application, and regulatory agency interfacing for processing facility compliance; staffcommunication; SOP and inspection evaluation; metrics alignment; oversight of employees andpackaging/labeling procedures; facility safety and cleanliness; monitoring of safes, vaults, and secureareas authorization. Monitors record keeping to insure compliance with all relevant Ohio regulations.Emily will define long-term goals and help forecast and meet goals through adherence to stateregulations and laws, using her experience in dispensary management and implementation nationallyto create a compliant, successful dispensary organization.
Clinical/Medical Director (Mitch Fields): Accountability for patient care standards, dispensary staff
conduct; physician/employee educational/training material development; patient education/supportimprovement; guidance and product recommendations; research; risks, benefits, and product sideeffects education; and substance abuse guidelines/enforcement. Qualifications: 31 years orthopedicsurgery experience and founding owner of a medical practice, pain management patient counseling,Doctor of Medicine, medical marijuana education.
Controller/Administration Director (Kay Howe): Human resources development and recordkeeping;BoP new hire notification; workflow processes and SOP updating; company asset protection; andfinancial, worker’s comp, and executive audits. Qualifications: 10 years HR experience/organizationaldevelopment; 5 years accounting/finance, leadership, collaboration, and relationship orchestration;management/stakeholder communication; CPA; and administration skills.
Engineering & Process Manager (Ryan Wright): Designing, implementing, and improving dispensaryprocesses for high product quality at lower costs. Previous experience as an innovation categoryleader with several renowned food brands will bolster processes considerably. Qualifications: 5+ yearsengineering/processing and brand building.
Quality Assurance Director (Dieneka Manzanares): Compliance accountability, application, and agencyinterfacing; staff communication; SOP/inspection evaluation; metrics alignment; oversight of employeesand packaging/labeling; dispensary safety/cleanliness; safes, vaults, and security area monitoring.Dieneka’s long experience in another state’s medical marijuana dispensary market will aid her in thisrole considerably, and she will bring this experience to the dispensary to ensure product quality.
Community Relations, Outreach, Social Media, & Marketing Advisor (Michael Wesley Redd): Deliveryof high-quality, engaging Internet content and creation of community outreach initiatives. Michael’sprevious leadership/community involvement experience will translate into excellent communication withpatients and community.
Governmental Affairs Advisor (Alan Stockmeister): Management of critical community relationships,local organization partnerships, legislation monitoring, and compliance findings reports. Alan’s previousexperience in education, banking, healthcare, and economic development organizations will contributeto success and compliance. To address Ohio’s philanthropic funding inequality, the dispensary willfocus on providing education, health/human services, and development for the community through theFoundation of Appalachian Ohio, which Alan will lead.
Supply Chain Advisor (Kenneth Triplett): Supply chain management including sales/operation planning,product inventories, logistics/returns/carrier planning, and forecasting. Kenneth’s previous experiencein international retail business will ensure an efficient/compliant product plan.
Retail Sales Director (Robert Munn): Sales facilitation for sustainable growth/product guidance.Robert’s previous experience in restaurant franchising and leadership in community/health services willallow the dispensary to create the safest, highest-quality products.
Brand Ambassador & Advisor (Walt Dennis): Execution of sustainable, measurable brand strategy andincreasing brand awareness/sales. Walt’s exemplary international product manufacturing, marketing,and sales experience will help the dispensary exceed compliance/ regulatory standards.
Insurance, Surety, & Financial Advisor (Michael Shawd): Providing expert guidance on finance,insurance, underwriting, and surety solutions. Michael’s previous experience in insurance, banking,and finance will help the dispensary keep investments, patients, and employees safe always.
C-4.2 Please attach a Table of Organization and Control for the business. Include all individuals listedin question A-6.
Patient Advocate and Medical Advisor (Dr. Rodney Stout): Patient and employee guidance on producttreatment options. Rodney’s previous experience as physician at Holzer Health will allow him tocompliantly guide patients/employees to appropriate medications.
Patient Advocate and Pharmaceutical Advisor (Natalie Ring): Guidance and creation of comfortableand accessible experiences for patients. Natalie’s pharmacy experience in edibles and advancedcompounding will lend unparalleled compliance with the BoP/MMCP; her experience will also provideconsistent, high-quality, and safe products.
Dispensary Compliance Control Manager (Ben Jones): Compliance requirements/product qualitycontrols, brand recognition building for products, and creation of patient education information with Dr.Rodney Stout and Emily Cohen.
Uploaded Document Name: C-4.2_Table of Organization & Control.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Business Plan(Capital Requirements)
Item 1 of 6
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)
Checking Account
Kevin Lykens
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5_Proof of Adequate Liquid Assets - REDACTED - PAKE 1 -Huntington (1).pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Business Plan(Capital Requirements)
Item 2 of 6
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)
Checking Account
Kevin Lykens
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5_Proof of Adequate Liquid Assets - REDACTED - PAKE 1 -Huntington (1).pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Business Plan(Capital Requirements)
Item 3 of 6
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)
Money Market Account
Kevin Lykens
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5_Proof of Adequate Liquid Assets - REDACTED - PAKE 1 -Huntington (1).pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Business Plan(Capital Requirements)
Item 4 of 6
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)
Liquidity Access Line
Michael Redd
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5_Proof of Adequate Liquid Assets - REDACTED - PAKE 2 -Morgan Stanley (1).pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Investments and services offered through Morgan Stanley Smith Barney LLC, member SIPC.
© Morgan Stanley Bank, N.A. Member FDIC.
Morgan Stanley Bank, N.A. One Utah Center 201 South Main Street, 5th Floor Salt Lake City, UT 84111
November 9, 2017
Re: Your Liquidity Access Line (LAL) No.
Per your request, please accept this letter as confirmation that the below is effective as of November 9, 2017:
Total Advance Limit (which is the maximum amount of credit that may at any time be available
under your LAL based on the maximum lending value of pledged collateral ): is in excess
of:$1,000,000.00
Your LAL with Morgan Stanley Bank, N.A. ("Morgan Stanley") is governed by the terms of the Liquidity
Access Line Application and Agreements and the related Liquidity Access Line Terms and Conditions
(collectively, the "Agreement"; defined terms used herein but not otherwise defined shall have the meanings set
forth in the Agreement). Pursuant to Sections 1(D) and 2(B) of the Terms and Conditions, Morgan Stanley may
modify your Interest Spread and Total Advance Limit, from time to time, in its sole and absolute discretion.
The Total Advance Limit may be lowered if, among other things, the collateral pledged to secure your LAL
declines in value for any reason.
Morgan Stanley retains all its rights under the Agreement, including, without limitation, its ability to demand
repayment of amounts outstanding under the LAL, in whole or in part, at any time and without prior notice, and
thereafter to exercise any of the remedies set forth in the Agreement. In the event of any conflict between the
terms of this letter and the terms of the Agreement or other Loan Documents, the terms of Loan Documents
shall govern in all respects.
If you have questions, please do not hesitate to call our Client Service Center at 800-355-3086, or contact your
Morgan Stanley Wealth Management Financial Advisor or Private Wealth Advisor to start using your Liquidity
Access Line today.
Sincerely,
Morgan Stanley Bank, N.A.
TRADE SECRET
Business Plan(Capital Requirements)
Item 5 of 6
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)
Checking Account
Ryan Wright
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5_Proof of Adequate Liquid Assets - REDACTED - PAKE 3 - OVB(1).pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Business Plan(Capital Requirements)
Item 6 of 6
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)
Credit Line Account
Kevin Lykens
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5_Proof of Adequate Liquid Assets - REDACTED - PAKE 4 - UBSAccount Info Letter (1).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
David
Leroy
Johns
Person Exercising Substantial Control
Ascena Retail Group
200 Heritage Dr, Pataskala, OH 43062
YES
March 2013-October 2016
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
Kenneth
Neil
Triplett
Owner
Trippies, Inc.
287 Elam Rd. Jackson, Ohio 45672
YES
1974 - 2007
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
Kevin
Lynn
Lykens
Owner
Lykens Companies, LLC
1020 Dennison Ave, Columbus, OH 43201
YES
1999 - 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
Michael
Wesley
Redd
Support Employee
Milwaukee Bucks
1543 North 2nd Street, 6th Floor, Milwaukee, WI 53212
YES
2000-2012
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
Charles
Mitchell
Fields
Owner
Chillicothe Bone & Joint Specialists, Inc
4457 State Route 159, Chillicothe, OH 45601
YES
1984-2016
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
Robert
Allen
Munn
Owner
Jackdon, LTD (McDonalds)
588 E Main St. Jackson, OH 45640
YES
1979-2012
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
Ryan
Kelly
Wright
Officer
Belliso Foods, Inc.
100 E Broadway Street, Jackson, Ohio 45640
YES
1994 - Current
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
Michael
James
Shawd
Owner
Goddard-Shawd Insurance Agency
P O Box 160, Barlow, OH 45712
YES
1993-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
Seth
Alan
Stockmeister
Owner
Stockmeister Enterprises, Inc.
704 E Main St, Jackson, Ohio 45640
YES
1994-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
Walter
Edwin
Dennis
Owner
HFI, LLC
59 Gender Rd, Canal Winchester, OH 43110
YES
1981 - 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
Natalie
Jane
Ring
Support Employee
Lima Memorial Hospital
1001 Bellefontaine Ave, Lima, OH 45804
YES
2014-2016
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
Rodney
Barry
Stout
Person Exercising Substantial Control
Holzer Clinic, LLC
90 Jackson Pike, Gallipolis, OH 45631
YES
1995-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
Alan
Arthur
Stockmeister
Owner
Foremost Management, LLC
702 East Main St. Jackson, Ohio 45640
YES
1992 - 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
Kay
Ann
Howe
Person Exercising Substantial Control
Foremost Management, LLC
702 East Main St. Jackson, Ohio 45640
YES
1994-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
Benjamin
Charles
Jones
Person Exercising Substantial Control
Plan C Life, Inc d/b/a Lola Lola
1080 Folsom St. San Francisco, CA 94103
YES
3/1/17 - Present
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
Dieneka
None
Manzanares
Owner
Sweet Leaf Pioneer
1286 Chambers Ave # 105 & #101, Eagle, CO 81631
YES
2010-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
Joseph
Max
Cohen
Owner
The Clinic
12 S Broadway Suite 220, Denver, CO 80209
YES
November 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
Emily
Rachel
Cohen
Officer
The Clinic
12 S Broadway Suite 220, Denver, CO 80209
YES
February 2014 - Present
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. TRADE SECRET
Elevate 1803’s executive team has extensive business experience, including medical marijuana facilityexperience, and many completed industry training workshops with highly-respected organizationsincluding medical professionals/industry business operators.
The executive team has been involved in the medical marijuana regulated industry withcultivation/processing/dispensary facilities; large-scale, indoor commercial food production meetingUSDA/FDA regulations; and 26 years of healthcare operations experience at nursing homes, clinics,pharmacies, and hospitals.
The executive team holds or has held licenses in construction, insurance services, CPA, healthcarepractices/facilities; Board of Pharmacy (BoP) terminal distributor of dangerous drugs,pharmacist/professional designations, and medical marijuana facilities licenses in other states. Theteam implemented a business plan with timelines to leverage operating assets, outlining a multi-million-dollar line of credit/facility retrofitting.
Emily Cohen has several years of experience in the medical marijuana industry in other states,including experience developing dispensaries. Emily’s extensive knowledge of industry startup,compliance, regulations, and industry trends will help the organization excel.
Max Cohen is the founder & CEO of The Clinic, an award winning dispensary with presence in multiplestates. He is also the founding member of a marijuana policy and lobbying organization and has wonnumerous industry awards personally and through his various businesses. Max has startup and verticalintegration experience he brings to the dispensary to design and operate a successful organization.
Kevin Lykens, CPA, creates, updates, and tracks financial plans for companies, investors, and bankswith internal controls and metrics like annual budgets, pro forma income statements, balance sheets,and cash flow statements.
David Johns recently retired as Chief Information Officer (CIO) of a $7.2B retailer with 6 brands, 5000+retail stores and a $1B online business. David was also CIO of a $6B+ manufacturer, tracked inventoryusing ERP systems, protected confidential patient information, and managed efficient supply chains tomeet costs and satisfy clients. David’s previous responsibilities in healthcare, pharmaceutical, banking,and finance included information security for millions of customers’ personal information.
The executive team has managed or owned various businesses requiring 24-hour security monitoringwith full-time guards, metal detectors, security protocols, and perpetual inventory software. They haveimplemented product chains of custody, signed off by multiple persons upon transportation, and haveexperience in armored car use.
Elevate 1803’s executive team is experienced in market differentiation, and will use marketing,
branding, strict compliance, and high-quality medical cannabis products to establish and maintainmarket integrity.
Advisory Board Member Natalie Ring is a licensed Pharmacist in multiple states including the OhioState Board of Pharmacy.
Robert Munn is a former educator/coach who started a career in food & beverage with McDonalds.Robb’s franchises grew to four stores, 300 jobs and seven Outstanding Store awards. Robb heldleadership positions with United Fund, YMCA, Chamber of Commerce, and Jackson County HealthServices.
Mitchell Fields holds a B.S. and an M.D. from The Ohio State University. He founded an orthopedicsurgical practice specializing in Sports Medicine, total knee and hip replacement. Mitchell is a lifelongOhio resident who developed deep bonds with his surgical patients and believes in the benefits ofmedical marijuana.
Born in Columbus, Ohio, Michael Wesley Redd led Ohio State to the Final Four in 1999. Drafted by theMilwaukee Bucks, he played until 2012. In 2008, Michael played on the gold medal-winning USOlympic Basketball Team. Michael founded The Wave Ministries, a faith-based, non-denominationalorganization dedicated to personal transformation. Michael is an Ohio State University graduate and aventure partner of Third Wave Ventures, a digital technology company.
Kevin Lykens, CPA, graduated from The Ohio State University and is a native Ohioan. His experienceincludes auditing work at the Financial Institutions Group where he performed over 10,000 bank andcredit union audits. Kevin founded Lykens Companies, a residential commercial development andmanagement company specializing in urban and historic redevelopments.
Ryan Wright is the VP of Engineering & Maintenance for Bellisio Foods, a category leader in innovationwhich ships frozen foods throughout North America. Bellisio is a privately held company with whollyowned brands Michelina’s, Eating Well, SoRight and EAT. Bellisio produces entrees for Newman’sOwn, Zatarain’s (McCormick’s), Farm Rich, General Mills, and Boulder Brands. At Bellisio, Ryanproduces over 2 million meals and 100 tons of pizza rolls daily.
Kenneth Triplett worked for the Standard Oil Bulk Plant in Chillicothe as an Administrator. In 1972, hejoined the U.S. Army, serving in Göeppingen, Germany. Following honorable discharge, Kennethfounded one of Jackson County’s most prominent business ventures, Trippies, Inc., importing giftwarefrom China, Taiwan, and other Asian countries. Kenneth now advises several insurance, distribution,and logistics companies. Kenneth sold Trippies, Inc. in 2007.
David Johns has 22 years of C-Level executive experience: CIO, Chief Supply Chain Officer and ChiefShared Services Officer. His executive roles were with a $7.2 women’s specialty Retailer and a $6B+global manufacturer. He holds a B.S. in Computer Science Engineering from The Ohio State Universityand an MBA from The University of Dayton. He was inducted into the CIO Hall of Fame in 2009.
Michael Shawd’s company Goddard-Shawd Insurance Agency is an independent insurance agencyserving Southeastern Ohio counties. Michael holds licenses in Property, Casualty, Life and Health.Mike’s experience includes: AVP of Loans, Bank Examiner for the Ohio Department of Commerce,CSBS Bank Examiner instructor, and Bank Consultant. Michael holds a B.S. in BusinessAdministration with a major in Accounting from The Ohio State University.
Walter Dennis is Non-Executive Chairman and founder of HFI, LLC, a leading supplier for the North
American Automotive Industry. HFI headquarters is in Canal Winchester, Ohio, with manufacturingfacilities in three states, five cities in Mexico and offices in Detroit, Michigan. HFI employs over 4,000people with $250 million plus in revenue. He holds a B.S. degree in sales with a minor in marketing.Walter is on the Ohio State University Foundation Board, and has been board chair of NorthwestCounseling Services and Recreation Unlimited.
Seth Stockmeister, a third-generation owner/operator of the family businesses, has been involved inlarge-scale construction projects for institutional, healthcare, commercial and industrial manufacturing,and processing across the U.S. Seth holds a B.S. in Construction Management and Technology, andan OSHA 10 & 30 Hour certification in CFR 1926. Training included inspections, accident investigation,personnel monitoring, and record keeping. Seth holds licenses with the state Department ofCommerce, Construction Industry Licensing Board, and the Board of Pharmacy. Seth has beeninvolved in projects for universities, research facilities, and licensed pharmacies.
Natalie Ring earned her Pharm. D and completed advanced compounding. As a pharmacist, Nataliewas a part of CVS Pharmacy for six years. Following her work with CVS, she served as ClinicalPharmacist for Lima Memorial Hospital. She holds licenses in Ohio, Massachusetts, Connecticut, NewYork, Florida, North Carolina and is passionate about patient care and regulatory compliance.
Alan Stockmeister earned a B.S. from Michigan State University, and is owner/president of ForemostManagement, Inc., a Jackson construction management, development, and property managementfirm. He has built construction, development, and operation of healthcare facilities businesses such asnursing homes, clinics, pharmacies, hospitals, manufacturers, farms, and theaters, employingthousands. Alan serves as a Trustee to The Ohio State University, and holds a Governor’sappointment as Grand Commodore of the Association of Ohio Commodores. Alan served hiscommunity as an advisor or board member on education, banking, skilled nursing facilities, extendedcare facilities, hospitals, pharmacies, clinics, foundations, and economic development.
A native, Kay Howe attended The University of Toledo and graduated with a Bachelor of Administrationin accounting. Kay served six years as Medic in the Ohio National Guard. Upon completion of militaryservice, Kay worked as a financial auditor for Deloitte and Touche in Atlanta. Kay returned to southernOhio where she serves as Chief Financial Officer for numerous corporations. Her experience includestreasury management, inventory systems and controls such as integrating scales into the inventorysystems, financing, and human resources.
Dr. Rodney Stout practices Endocrinology, Diabetes, and Metabolism at Holzer Health System inSoutheastern Ohio. Having completed his B.S. in Chemistry, Magna Cum Laude, Dr. Stout completedhis Doctor of Medicine from the University of Missouri. From December 2016-present, Dr. Stout servesas Chief Medical Officer at Holzer Health System. Prior to that, he served as Medical Director of theResearch Department at Holzer Clinic. Since 2005, he has served as Principal Investigator for Holzer.
Dieneka Manzanares, CEO of Sweet Leaf Pioneer medical marijuana dispensary, has eight yearsexperience in cultivation and dispensary entrepreneurship including lean manufacturing, quality control,regulatory compliance, and community outreach. Before opening her first marijuana business, Dienekaowned a bookkeeping business and was a personal banker and banking advisor.
Ben Jones has built brand recognition and established clientele for cannabis startups, providing qualitymedicine to patients. As manager of Lola Lola a well-respected dispensary in California, Ben doubledgross sales in six months by implementing improvements in products, packaging, and patienteducation.
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_Security and Surveillance Measures Optional AdditionalInformation.pdfNOTE: This applicant uploaded document is the next 5 page(s) of this document.
1
2
3
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
3
Positive HIV status Skin and rashes and sores, swollen glands, infections, fever, night sweats
Post-traumatic stress disorder (PTSD) Hyperarousal, nightmares, flashbacks, negative beliefs, depression, anger
Sickle-cell anemia Anemia, pain episodes, painful hand and feet swelling, frequent infections, vision problems
Spinal cord disease or injury Complete or partial loss of feeling or control of parts of the body, paraplegia, loss of sensation
Tourette syndrome Simple or complex tics, grunting, coughing, throat clearing, obscenities
Traumatic brain injury (TBI) Consciousness loss, nausea, headache, fatigue, dizziness, sleeping difficulties, light or sound sensitivity
Ulcerative colitis Diarrhea, rectal pain, abdominal pain and cramping, urgency, weight loss, fatigue, and fever
Operations Plan D-5.5_Dispensing of Product Optional Additional Information
Chart of Qualifying Conditions
TRADE SECRET
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
described in E-3.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: E-3.1 Patient Care Facilities Optional Additional Information Location5.pdfNOTE: This applicant uploaded document is the next 2 page(s) of this document.
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
7:00am - 7:00pm EST, or as required by market demand and permitted by the State of Ohio.
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 2 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