ohio medical marijuana dispensary application gti ohio ......a-6.9 types of shares owned a-6.10...
TRANSCRIPT
Ohio Medical Marijuana Dispensary Application
GTI OHIO, LLC Application ID 495
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
GTI Ohio, LLC
N/A
18605 Detroit Ave
Lakewood
OH
44107
2162215070
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
Robert
T.
George
18605 Detroit Ave
Lakewood
OH
44107
2162215070
---
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
04/07/2017
GTI Ohio, LLC
This response has been entirely redacted
No response provided by applicant
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
NORTHEAST-2
Cuyahoga
Demographic Information(Prospective Associated Key Employees Details)
Item 1 of 34
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
Andrew
Lawrence
Grossman
No response provided by applicant
No response provided by applicant
Owner
TBD
8%
Membership interests
8%
8%
OWNER
No response provided by applicant
--
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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
8218 Pumpkin Hill Ct
Baltimore
MD
21208
4436025477
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 2 of 34
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
Anthony
Bernard
Giardini
No response provided by applicant
Attorney
Owner
TBD
10%
Membership interests
10%
10%
OWNER
No response provided by applicant
--
-
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
209 W Marina Parkway
Lorain
OH
44052
4407592920
No response provided by applicant
66 years
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 34
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
No response provided by applicant
George
No response provided by applicant
No response provided by applicant
Chief Executive Officer
TBD
40%
Membership interests
40%
40%
OFFICER
No response provided by applicant
--
-
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
18605 Detroit Ave
Lakewood
OH
44107
2166506741
No response provided by applicant
36 years
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 34
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
No response provided by applicant
George
No response provided by applicant
Attorney
Owner
TBD
10%
Membership interests
10%
10%
OWNER
No response provided by applicant
--
-
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
2468 Brantwood Ave
Westlake
OH
44145
2169526223
No response provided by applicant
38 years
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 34
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
Peter
Albert
Kadens
No response provided by applicant
Business executive
Chairman
TBD
8%
Membership interests
8%
8%
BOARD MEMBER
No response provided by applicant
--
-
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
244 Mary St
Winnetka
IL
60093
3122824281
No response provided by applicant
N/A
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 34
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
No response provided by applicant
Kovler
No response provided by applicant
Business executive
Managing Chairman
TBD
8%
Membership interests
8%
8%
BOARD MEMBER
No response provided by applicant
--
-
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
875 N Michigan Ave, Suite 3400
Chicago
IL
60611
4156092629
No response provided by applicant
N/A
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 34
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
Eugene
Christopher
Green-Monroe
No response provided by applicant
Investor
Chief Diversity & Community Outreach Officer
TBD
8%
Membership interests
8%
8%
OFFICER
No response provided by applicant
--
-
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
12219 Garrison Forest Rd
Owings Mills
MD
21117
4342495723
No response provided by applicant
N/A
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 34
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
Anthony
Valentino
Georgiadis
No response provided by applicant
Business executive
Chief Operating Officer
TBD
8%
8%
Membership interests
8%
OFFICER
No response provided by applicant
--
-
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
727 S Edison Ave
Tampa
FL
33606
7042873447
No response provided by applicant
N/A
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 34
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
Deborah
Ann
Berlekamp
No response provided by applicant
Pharmacist
Patient Education & Advocacy Director
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
903 Pine St
Perrysburg
OH
43551
4199447181
No response provided by applicant
35 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 10 of 34
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
Lonzo
No response provided by applicant
Coleman
No response provided by applicant
Business executive
Board member; Diversity and Community Outreach Advisory Board Member
TBD
0
N/A
0
0
BOARD MEMBER
No response provided by applicant
--
-
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
32745 Shadowbrook Dr
Cleveland
OH
44139
2164318070
No response provided by applicant
67 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 11 of 34
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
No response provided by applicant
Dobeck
No response provided by applicant
Security Consultant
Security Director
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
3108 Whispering Shores Dr
Vermilion
OH
44089
2165510207
No response provided by applicant
18 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 12 of 34
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
Jillian
Valerie
Dura
Pharm.D, CNMT
Pharmacist
Board member
TBD
0
N/A
0
0
BOARD MEMBER
No response provided by applicant
--
-
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
1166 Fireside Trail
Broadview Heights
OH
44147
7163087387
No response provided by applicant
8 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 13 of 34
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
Nicholas
Joseph
Etten
No response provided by applicant
Executive Director - Nonprofit organization
Veterans advisory board member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
1001 Green Bay Road #184
Winnetka
IL
60093
5129927567
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 14 of 34
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
Kenneth
Ezinga
No response provided by applicant
Real Estate Developer
Sustainability Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
441 Route 66
Hudson
NY
12534
4405749521
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 15 of 34
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
Jose
Celso
Feliciano
Jr
External Affairs Manager
Diversity and Community Outreach Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
200 Sandover Drive
Aurora
OH
44202
4407083744
No response provided by applicant
37 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 16 of 34
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
Mildred
Forbes
Beal
No response provided by applicant
Attorney/Consultant
Regulatory Compliance Director; Diversity and Community Outreach Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
11430 Bellflower Road
Cleveland
OH
44106
7047791983
No response provided by applicant
3 months
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 17 of 34
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
Terrance
William
Gainer
No response provided by applicant
Security Consultant
Chief Security Officer
TBD
0
N/A
0
0
OFFICER
No response provided by applicant
--
-
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
9743 S Hamilton Ave
Chicago
IL
60643
2023555897
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 18 of 34
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
Sean
No response provided by applicant
Hayes
No response provided by applicant
VP - Solar company
Sustainability Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
2405 Mandy Lane
Hillsborough
NC
27278
3175149810
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 19 of 34
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
Patricia
No response provided by applicant
Jamieson
No response provided by applicant
Accountant
Chief Financial Officer; Diversity and Community Outreach Advisory Board Member
TBD
0
N/A
0
0
OFFICER
No response provided by applicant
--
-
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
412 South Stonehaven Drive
Highland Heights
OH
44143
4406840704
No response provided by applicant
62 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 20 of 34
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
Anthony
William
Makarich
Pharm.D
VP - Pharmacy Operations
Operations Director
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
8059 Shackelford Dr
Frisco
TX
75035
4408364200
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 21 of 34
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
Jack
Dean
McCue
No response provided by applicant
Physician
Board member; Chief Medical Officer; Medical Advisory Board Member
TBD
0
N/A
0
0
BOARD MEMBER
No response provided by applicant
--
-
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
2234 SE 47th Ave
Portland
OR
97215
2097284715
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 22 of 34
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
John
Peter
Pardee
No response provided by applicant
Environmental Consultant
Patient Advocacy Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
47391 Garfield Rd
Oberlin
OH
44074
4403152735
No response provided by applicant
55 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 23 of 34
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
Dina
No response provided by applicant
Rollman
No response provided by applicant
Attorney
Chief Compliance Officer
TBD
0
N/A
0
0
OFFICER
No response provided by applicant
--
-
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
680 Kincaid St
Highland Park
IL
60035
7738525526
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 24 of 34
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
Lee
Schnee
No response provided by applicant
Physician
Medical Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
3511 Anton Farms Road
Pikesville
MD
21208
8189836136
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 25 of 34
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
Robin
Michelle
Star
No response provided by applicant
Parent Coach
Medical Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
35677 Quartermane Circle
Solon
OH
44139
4406683701
No response provided by applicant
17 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 26 of 34
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
Anthony
No response provided by applicant
Thomas
No response provided by applicant
Social Worker
Diversity and Community Outreach Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
802 Sharon Dr, Suite A
Westlake
OH
44145
4403522330
No response provided by applicant
60 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 27 of 34
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
Annie
No response provided by applicant
Tran
MBA, Pharm.D
Pharmacist
Dispensary Manager
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
16781 Chagrin Blvd, Suite 450
Shaker Heights
OH
44120
6083951057
No response provided by applicant
3 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 28 of 34
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
Raymond
No response provided by applicant
Wood
No response provided by applicant
NAACP President
Board member; Diversity and Community Outreach Advisory Board Member
TBD
0
N/A
0
0
BOARD MEMBER
No response provided by applicant
--
-
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
596 Weirwood Drive
Toledo
OH
43607
4193922470
No response provided by applicant
10 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 29 of 34
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
Ellen
Jean
Wrice
No response provided by applicant
Retired
Diversity and Community Outreach Advisory Board Member
TBD
0
N/A
0
0
OTHER
No response provided by applicant
--
-
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
1034 MLK Blvd West 21st
Lorain
OH
44052
4402420174
No response provided by applicant
67 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 30 of 34
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
Bret
David
Kravitz
No response provided by applicant
Counsel
Chief Legal Officer
TBD
0
N/A
0
0
OFFICER
No response provided by applicant
--
-
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
325 W Huron St, Stre 412
Chicago
IL
60654
3127946720
No response provided by applicant
5 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 31 of 34
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
N/A
No response provided by applicant
RCP23, LLC
No response provided by applicant
No response provided by applicant
Financial Lender
TBD
0
N/A
0
0
PERSON WITH FINANCIAL INTEREST
No response provided by applicant
--
-
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
325 W Huron St, Ste 412
Chicago
IL
60654
3127946720
No response provided by applicant
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 32 of 34
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
N/A
No response provided by applicant
Ohio Investors 2017, LLC
No response provided by applicant
No response provided by applicant
Owner Holding Company (see Applicant org chart)
N/A
100%
Membership interest
100%
100%
OWNER
Capitalized applicant for purposes of this application and operating under a medical marijuana
--
-
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
dispensary license, if awarded a license
This response has been entirely redacted
This response has been entirely redacted
325 W. Huron St, Ste 412
Chicago
IL
60654
3127946720
No response provided by applicant
N/A
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 33 of 34
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
N/A
No response provided by applicant
GTI Core, LLC
No response provided by applicant
No response provided by applicant
Owner Holding Company (see Applicant org chart)
N/A
40%
Membership interest
40%
40%
OWNER
Capitalized applicant for purposes of this application and operating under a medical marijuana
--
-
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
dispensary license, if awarded a license
This response has been entirely redacted
This response has been entirely redacted
325 W Huron St, Ste 412
Chicago
IL
60654
3127946720
No response provided by applicant
N/A
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 34 of 34
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
N/A
No response provided by applicant
George Management Ltd.
No response provided by applicant
No response provided by applicant
Owner Holding Company (see applicant org chart)
N/A
60%
Membership interest
60%
60%
OWNER
Capitalized applicant for purposes of this application and operating under a medical marijuana
--
-
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
dispensary license, if awarded a license
This response has been entirely redacted
This response has been entirely redacted
18605 Detroit Avenue
Lakewood
OH
44107
2166506741
No response provided by applicant
N/A
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
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 34
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.
Andrew
Lawrence
Grossman
OWNER
Owner
Advise operations of dispensary
YES
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
YES
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.
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
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.
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 any
No response provided by applicant
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
state?
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?
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
NO
No response provided by applicant
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 2 of 34
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.
Anthony
Bernard
Giardini
OWNER
Owner
Advise operations of dispensary
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 3 of 34
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.
Robert
No response provided by applicant
George
OFFICER
Chief Executive Officer
Work in partnership with the Board of Directors and provide leadership in achieving Applicant’s vision,mission, strategy, and annual goals.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 4 of 34
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.
Joseph
No response provided by applicant
George
OWNER
Owner
Advise operations of dispensary
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 5 of 34
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.
Peter
Albert
Kadens
BOARD MEMBER
Chairman
Oversee the Board of Directors, which will establish, guide, and evaluate Applicant’s strategic plan andfinancial goals and advise the Chief Executive Officer on matters related to business strategy.
YES
3C Compassionate Care Center, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Mundelein, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Nevada, LLC
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.
325 W Huron St, Ste 412Chicago, IL 60654
GTI Oglesby, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Rock Island, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
NH Medicinal Dispensaries, LLC d/b/a The Clinic Effingham1011 Ford Ave., Suite CEffingham, IL 62401
YES
3C Compassionate Care Center, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Mundelein, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Nevada, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Oglesby, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Pennsylvania, 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, License
325 W Huron St, Ste 412Chicago, IL 60654
GTI Rock Island, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
NH Medicinal Dispensaries, LLC d/b/a The Clinic Effingham1011 Ford Ave., Suite CEffingham, IL 62401
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
Number, 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.
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?
No response provided by applicant
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
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?
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
NO
No response provided by applicant
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 6 of 34
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.
Benjamin
No response provided by applicant
Kovler
BOARD MEMBER
Managing Chairman
Oversee the Board of Directors, which will establish, guide, and evaluate Applicant’s strategic plan andfinancial goals and advise the Chief Executive Officer on matters related to business strategy.
YES
3C Compassionate Care Center, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Mundelein, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Nevada, LLC
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.
325 W Huron St, Ste 412Chicago, IL 60654
GTI Oglesby, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Rock Island, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
NH Medicinal Dispensaries, LLC d/b/a The Clinic Effingham1011 Ford Ave., Suite CEffingham, IL 62401
YES
3C Compassionate Care Center, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Mundelein, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Nevada, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Oglesby, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Pennsylvania, 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, License
325 W Huron St, Ste 412Chicago, IL 60654
GTI Rock Island, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
NH Medicinal Dispensaries, LLC d/b/a The Clinic Effingham1011 Ford Ave., Suite CEffingham, IL 62401
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
Number, 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.
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?
No response provided by applicant
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
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?
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
NO
No response provided by applicant
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 7 of 34
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 or
Eugene
Christopher
Green-Monroe
OFFICER
Chief Diversity & Community Outreach Officer
Oversee the programs that promote diversity of Applicant's operations. Serves on Diversity andCommunity Outreach Advisory Board.
YES
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
Advanced Biomedics, LLC1019 Coolidge StLafayette, LA 70503
financial 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.
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, Nature
YES
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
Advanced Biomedics, LLC1019 Coolidge StLafayette, LA 70503
NO
No response provided by applicant
NO
No response provided by applicant
NO
of 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.
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 any
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
YES
other 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?
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
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 8 of 34
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 or
Anthony
Valentino
Georgiadis
OFFICER
Chief Operating Officer
Responsible for day-to-day operations and the development, design, and improvement of the policiesand procedures to ensure Applicant’s medical marijuana products meet or exceed quality standards.
YES
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Nevada, LLC325 W Huron St, Ste 412Chicago, IL 60654
financial 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.
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, Nature
YES
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Nevada, LLC325 W Huron St, Ste 412Chicago, IL 60654
NO
No response provided by applicant
NO
No response provided by applicant
NO
of 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.
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 any
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
YES
other 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?
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
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 9 of 34
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.
Deborah
No response provided by applicant
Berlekamp
OTHER
Patient Education & Advocacy Director
Serve on Patient Advocacy Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 10 of 34
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.
Lonzo
No response provided by applicant
Coleman
BOARD MEMBER
Board member; Diversity and Community Outreach Advisory Board Member
Serve on Board of Directors and on Diversity and Community Outreach Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 11 of 34
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.
Michael
No response provided by applicant
Dobeck
OTHER
Security Director
Oversee physical site security and safety
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 12 of 34
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.
Jillian
Valerie
Dura
BOARD MEMBER
Board member
Responsible for management and supervision of dispensary staff including ensuring compliance withall inventory management, security protocols and record keeping procedures.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 13 of 34
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.
Nicholas
Joseph
Etten
OTHER
Veterans Advisory Board Member
Serve on Veterans Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 14 of 34
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
Kenneth
Ezinga
OTHER
Sustainability Advisory Board Member
Serve on Sustainability Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 15 of 34
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.
Jose
Celso
Feliciano
OTHER
Diversity and Community Outreach Advisory Board Member
Serve on Community Outreach Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 16 of 34
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.
Mildred
Forbes
Beal
OTHER
Regulatory Compliance Director; Diversity and Community Outreach Advisory Board Member
Review and evaluate compliance issues and concerns and ensure Applicant is compliant with allapplicable local, State, and Federal laws and regulations.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 17 of 34
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.
Terrance
William
Gainer
OFFICER
Chief Security Officer
Oversee the installation and operation of physical site safety and security measures.
YES
3C Compassionate Care Center, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Mundelein, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Nevada, LLC325 W Huron St, Ste 412
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.
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 or
Chicago, IL 60654
GTI Oglesby, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Rock Island, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
NH Medicinal Dispensaries, LLC d/b/a The Clinic Effingham1011 Ford Ave., Suite CEffingham, IL 62401
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
misdemeanor) 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.
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.
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-3.17 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?
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:
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
YES
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. YES
Compliance(Prospective Associated Key Employee Compliance)
Item 18 of 34
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.
Sean
No response provided by applicant
Hayes
OTHER
Sustainability Advisory Board Member
Serve on Sustainability Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 19 of 34
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.
Patricia
No response provided by applicant
Jamieson
OFFICER
Chief Financial Officer; Diversity and Community Outreach Advisory Board Member
Provide both operational and programmatic support to the organization; act as the financialspokesperson for Applicant.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 20 of 34
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.
Anthony
William
Makarich
OTHER
Operations Director
Supervise the daily operations of the dispensary.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 21 of 34
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.
Jack
Dean
McCue
BOARD MEMBER
Board member; Chief Medical Officer; Medical Advisory Board Member
Advise on quality assurance and quality control; develops training materials and ensure incorporationof medical research advancements; serves on Medical Advisory Board.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 22 of 34
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.
John
Peter
Pardee
OTHER
Patient Advocacy Advisory Board Member
Serve on Patient Advocacy Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 23 of 34
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.
Dina
No response provided by applicant
Rollman
OFFICER
Chief Compliance Officer
Ensure Applicant is compliant with all Ohio regulations, as well as local, State and Federal law.
YES
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI-Massachusetts NP Corp325 W Huron St, Ste 412Chicago, IL 60654
GTI Mundelein, LLC875 N Michigan Ave, Suite 3400Chicago, IL 60611
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Rock Island, LLC875 N Michigan Ave, Suite 3400
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.
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, License
Chicago, IL 60611
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
Number, 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.
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?
No response provided by applicant
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
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?
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
NO
No response provided by applicant
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 24 of 34
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.
Charles
Lee
Schnee
OTHER
Medical Advisory Board Member
Serve on Medical Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 25 of 34
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.
Robin
Michelle
Star
OTHER
Medical Advisory Board Member
Serve on Medical Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 26 of 34
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.
Anthony
No response provided by applicant
Thomas
OTHER
Diversity and Community Outreach Advisory Board Member
Serve on Diversity & Community Outreach Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 27 of 34
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.
Annie
No response provided by applicant
Tran
OTHER
Dispensary Manager
Manage the daily operations of the dispensary.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 28 of 34
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.
Raymond
No response provided by applicant
Wood
BOARD MEMBER
Board member; Diversity and Community Outreach Advisory Board Member
Develop, implement and monitor the programs that promote diversity of Applicant's operations; serveon Diversity and Community Outreach Advisory Board.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 29 of 34
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.
Ellen
Jean
Wrice
OTHER
Diversity and Community Outreach Advisory Board Member
Serve on Diversity and Community Outreach Advisory Board
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 30 of 34
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.
Bret
David
Kravitz
OFFICER
Chief Legal Officer
Serve as General Counsel; participate in the definition and development of corporate policies,procedures and programs.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 31 of 34
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.
N/A
No response provided by applicant
RCP23, LLC
PERSON WITH FINANCIAL INTEREST
Financial Lender
Financial Lender
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 32 of 34
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.
N/A
No response provided by applicant
Ohio Investors 2017, LLC
OWNER
Owner Holding Company (see Applicant org chart)
Owns 100% of Applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 33 of 34
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.
N/A
No response provided by applicant
GTI Core, LLC
OWNER
Owner Holding Company (see Applicant org chart)
Owns 40% of Applicant
YES
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
YES
GTI Maryland, LLC325 W Huron St, Ste 412Chicago, IL 60654
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
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?
GTI Pennsylvania, LLC325 W Huron St, Ste 412Chicago, IL 60654
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-3.13.1 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.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other
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
No response provided by applicant
authorization 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
No response provided by applicant
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 34 of 34
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.
N/A
No response provided by applicant
George Management LTD
OWNER
Owner Holding Company (see Applicant org chart)
Owns 60% of Applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
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Business Plan(Property Title, Lease, or Option to Acquire Property Location)
C-1.1 Attach one of the following: Evidence of the Applicant’s clear legal title to or option to purchase the proposed site and facility.A fully-executed copy of the Applicant’s unexpired lease for the proposed site and facility and awritten statement from the property owner that the Applicant may operate a medical marijuanaorganization on the proposed site for, at a minimum, the term of the initial provisional license.Other evidence that shows that the Applicant has a location to operate its medical marijuanaorganization.
Uploaded Document Name: C-1.1_LOI to Lease DRL.pdfNOTE: This applicant uploaded document is the next 17 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
GTI Ohio, LLC
No response provided by applicant
18607-18609 Detroit Ave. Extension; Parcel #311-18-088
Lakewood
OH
44107
2162215070
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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_Site and Facility Plan DRL.pdfNOTE: This applicant uploaded document is the next 4 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 DRL.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
12650 Detroit Avenue ● 44107 ● (216) 529-6630 ● FAX (216) 529-5907
www.onelakewood.com 11/08/2017 REVISED 11/14/2017 Robert George GTI Ohio LLC 18605 Detroit Avenue Lakewood, Ohio 44107 Re: Docket No.11-27-17
APPROXIMATELY 18607-18609 DETROIT EXTENSION GTI Ohio LLC
Dear Robert George: At the meeting on 11/02/2017, the Lakewood Planning Commission considered the review and approval of a Conditional Use in order to operate a Medical Marijuana Dispensary; pursuant to Section 1129.02 - principal and conditional permitted uses. The property is located in a C2 - Commercial, Retail district. The Board decided to CONDITIONALLY APPROVE the application with the following stipulations:
• The new building is built to city code and approved by ABR, • The security plan is approved by the Chief of Police including cameras approval, • A security guard will be onsite for all hours, • Compliance to all ABR requirements, • Comply with all city permitting business licensing requirements, • A mandatory one year annual review, • Compliant with all state codes and licenses granted, • Conditional use is in effect upon legislation as of November 13, 2017, and • Approved bollards in front and rear of the building.
Please contact the Division of Housing and Building with any comments or concerns you may have at (216) 529-6270. Sincerely,
Katelyn Milius, Commission Secretary Planner, Planning and Development
PLANNING COMMISSION
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 Map 500ft DRL.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
C‐3.1.1BusinessStartupPlanAttachment Page2of2
TRADE SECRET
Applicant Job Fair Presentation
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 SECRET
Applicant has 13 medical marijuana dispensary licenses in 5 highly-regulated medical market states(Illinois, Nevada, Massachusetts, Maryland and Pennsylvania) and has assembled a robust team ofindividuals with the education and experience needed to successfully lead its Ohio medical marijuanadispensary. Applicant’s team of experts has substantial experience in medical marijuana and otherhighly-regulated businesses. Applicant’s staffing and education / training plan will ensure Applicantprovides safe, compassionate dispensing and patient care that is compliant with Chapter 3796 and allother local, state, and federal laws. Applicant will ensure its owners, board members, and officersobtain associated key employee licenses issued by the board of pharmacy (“Members”).
OWNERSApplicant’s owners’ primary responsibility is to ensure the Company complies with the provisionsgoverning associated key employees and that the Company operates its business in a compliantmanner. Applicant has 8 owners, some of whom will also serve as board members and/or officers.Specifically, the following owners will hold the following roles:
Peter Kadens – ChairmanBenjamin Kovler – Managing ChairmanRobert George – Chief Executive OfficerEugene Monroe – Chief Diversity + Community Outreach OfficerAnthony Georgiadis – Chief Operating Officer
Andrew Grossman, Joseph George, Anthony Giardini will not hold a director nor officer role.
BOARD OF DIRECTORSApplicant’s 6-member board will bring specialized expertise and perspective and provide seniormanagement with comprehensive guidance to many aspects of the Company’s business including:
Chairman – Peter Kadens• Leads all Board Members (“Members”)• Guides/mediates actions on business priorities/governance concerns• Appoints the chairpersons of committees, in consultation with Members• Works with CEO and Members to ensure resolutions are followed• Evaluates CEO performance; informally evaluates effectiveness of Members• Collaborates with CEO to determine Company strategy• Monitors financial planning/financial reports• Ambassador for business; interacts with stakeholders• Approves annual budget/capital expenditures
Managing Chairman – Ben Kovler• Works with Chairman to develop/implement officer staffing/transition plans• Performs Chairman responsibilities when necessary• Ambassador for business; interacts with stakeholders• Collaborates with CEO to determine Company strategy
Medical – Jack McCue, M.D.Jack holds an M.D. and has over 35 years’ experience as a practicing physician, has published 14books or monographs and more than 300 articles in medical journals, and has worked with more than8,000 patients who use medical marijuana over the past 5 years. As a Member, he will advise onmedical research/product developments that may impact business and incorporate his knowledge ofmedicine, marijuana and patient experiences to help the Company maximize the health benefits forpatients.
Pharmacist – Jillian Dura, PharmD, CNMTJillian is a Pharmacy Manager at the Cleveland Clinic and has more than 10 years’ experience inpharmacy retail operations. She currently serves as pharmacist in charge of 20 direct reports rangingfrom clinical pharmacists, nursing staff and certified pharmacy technicians. As a Member, she willadvise on best dispensing practices and patient education.
Business – Lonzo ColemanLonzo is the President of Coleman Spohn Corporation, a minority-owned construction and mechanicalcontracting company. He has more than 30 years’ experience as a corporate team leader. As aMember, he will advise on innovative approaches to improving operations.
Diversity – Raymond WoodRaymond is the President of the Toledo chapter of the NAACP and Vice President of UA Toledo AreaCAP Council. He also serves on numerous boards of nonprofit organizations. As a Member, he willhelp Applicant foster a culture that embraces diversity and inclusion and advise on how to implementrecruiting, hiring, and training procedures that foster a diverse and inclusive workforce.
CHIEF EXECUTIVE OFFICER• Works with Members/executive management to establish short- and long-range goals, strategies,plans and policies• Defines corporate vision and strategy• Establishes Company culture of compliance, safety, and patient satisfaction• Plans, develops, implements, directs and evaluates business's fiscal performance• Leads/manages to ensure that the mission and core values practiced• Motivates and leads a high-performance management team• Ensures organization has appropriate staffing to ensure compliance and financial procedures arebehind adhered to
CHIEF MEDICAL OFFICER• Develops/implements policies/procedures related to patient experience and education• Educates community physicians and patients on the benefits of medical marijuana• Advises on quality assurance and control• Conducts compliance trainings and inspections• Trains team members on medical-related protocols• Develops/maintains relationships with academic institutions for business and research collaboration• Oversees Patient Education and Advocacy Director
CHIEF INFORMATION OFFICER• Plans communications, events and activities for interaction between customers, the public, the media,and employees• Manages brand and reputation with the general public• Oversees recall messaging/communications plan
• Oversees information safety/security; HIPAA compliance• Oversees IT, Marketing and PR staff
CHIEF FINANCIAL OFFICER• Works with CEO and Chairman on long-range planning• Forms and fosters bank relationships• Reports on budgets, financial reports and financial trends• Develops and implements Applicant’s financial policies and procedures• Develops a reliable cash flow projection process and reporting mechanism• Oversees accounting staff
CHIEF OPERATING OFFICER• Works with CFO to create annual budget and operations plans• Directs operational policies, objectives, initiatives• Develops strategies to attain short- and long-term financial/operational goals• Establishes direction/focus of operations• Oversees Operations Director• Helps CEO establish Company culture of compliance, safety, and patient satisfaction
CHIEF COMPLIANCE OFFICER• Ensures Applicant acts in compliance with applicable laws and regulations• Helps define and develop corporate policies, procedures and programs; provides continuing counseland guidance on legal matters and implications• Creates and monitors system of auditing Company activities to ensure compliance• Oversees Regulatory Affairs Director
CHIEF LEGAL OFFICER• Works with CCO• Serves as Chief Counsel for business and Members
CHIEF SECURITY OFFICER• Oversees physical site safety/security• Leads operational risk management activities• Works with local law enforcement to establish transparency in operations• Oversees Security Director and training of security personnel
CHIEF DIVERSITY & COMMUNITY OUTREACH OFFICER• Develops/oversees Diversity Plan; ensures diversity goals are met• Works with local organizations, the community, management and staff to ensure a diverse culture• Uses input from all employees to modify Diversity Plan as needed• Guides Patient Education and Advocacy/HR Directors on meeting diversity goals
ADVISORY BOARD MEMBERSApplicant has formed and filled six different community and subject matter advisory boards (seeattached). The PAKEs on these advisory boards will serve in a volunteer capacity.Meetings/conference calls will be held monthly to develop recommendations to improve Applicant’soperations, including minimizing its environmental impact, increasing the diversity of its workforce,fostering positive community relations and incorporating advancements in medical research. Theirduties and obligations will include attending advisory board meetings, attending community meetingsand events, and staying abreast of developments that would impact dispensary operations.
C-4.2 Please attach a Table of Organization and Control for the business. Include all individuals listedin question A-6. Uploaded Document Name: C-4.2_Table of Organization and Control.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
Chief Medical Officer
Jack McCue, MD
Chief Diversity + Community
Outreach OfficerEugene Monroe
TABLE OF ORGANIZATION AND CONTROL – OWNERSHIP, BOARD OF DIRECTORS, AND OFFICERS
DIRECTOR CBUSINESS
Lonzo Coleman
DIRECTOR DDIVERSITY
Raymond Wood
Managing Chairman
Benjamin KovlerDIRECTOR AMEDICAL
Jack McCue, MD
CEORobert George
BO
AR
D
ChairmanPeter Kadens DIRECTOR B
PHARMACISTJillian Dura,
PharmD, CNMT
Chief Information
OfficerOPEN
Chief Financial Officer
Patricia Jamieson
Chief Operating OfficerAnthony
Georgiadis
Chief Compliance Officer
Dina Rollman, JD
Chief Legal Officer
Bret Kravitz, JD
Chief Security Officer
Terrance Gainer, JD
AKE AKE
AKE AKE
AKE AKE
AKE
AKE AKE AKE AKE AKE AKEAKEAKE
OW
NE
RSH
IP
RCP23, LLC
Financial Lender
AKE
40% GTI Core, LLC (AKE) 60% George Management LTD (AKE)• Anthony Georgiadis (AKE)- 8%• Andrew Grossman (AKE)- 8% • Peter Kadens (AKE)- 8% • Benjamin Kovler (AKE)- 8% • Eugene Monroe (AKE)- 8%
• Robert George (AKE)- 40%• Joseph George (AKE)- 10% • Anthony Giardini (AKE)- 10%
Ohio Investors 2017, LLC (AKE)
TRADE SECRET
GTI Ohio, LLC
TABLE OF ORGANIZATION AND CONTROL – BOARD OF DIRECTORS, OFFICERS, AND ADVISORY BOARDS
DIRECTOR CBUSINESS
Lonzo Coleman
DIRECTOR DDIVERSITY
Raymond Wood
Managing Chairman
Benjamin KovlerDIRECTOR AMEDICAL
Jack McCue, MD
CEORobert George
BO
AR
D
ChairmanPeter Kadens
Chief Medical Officer
Jack McCue, MD
DIRECTOR BPHARMACIST
Jillian Dura, PharmD, CNMT
Chief Information
OfficerOPEN
Chief Financial Officer
Patricia Jamieson
Chief Operating OfficerAnthony
Georgiadis
Chief Compliance Officer
Dina Rollman, JD
Chief Legal Officer
Bret Kravitz, JD
Chief Diversity + Community
Outreach OfficerEugene Monroe
Chief Security Officer
Terrance Gainer, JD
AKE AKE
AKE AKE
AKE AKE
AKE
AKE AKE AKE AKE AKE AKEAKEAKE
Medical Advisory Board• Jack McCue, MD (AKE)• Charles Schnee, MD (AKE)• Robin Star (AKE)
Sustainability Advisory Board• Sean Hayes (AKE)• Benjamin Ezinga (AKE)
Patient Advocacy Advisory Board• John Pardee, PharmD (AKE)• Patient Advocates
Veterans Advisory Board• Nicholas Etten (AKE)• OH Veteran Advocates
Diversity and Community Outreach Advisory Board• Lonzo Coleman (AKE)• Jose Feliciano (AKE)• Raymond Wood (AKE)• Patricia Jamieson (AKE)• Mildred Forbes Beal, JD (AKE)• Ellen Jean Wrice (AKE)• Anthony Thomas (AKE)• Eugene Monroe (AKE)
Applicant’s Community and Subject Matter Advisory Boards
Each individual is at least twenty-one years of age, per 3796:6-2-09(C).The following AKEs will not hold a Director nor Officer role: Andrew Grossman, Joseph George, Anthony Giardini and RCP23, LLC
TRADE SECRET
TABLE OF ORGANIZATION AND CONTROL– CROSS-FUNCTIONAL
DIRECTOR CBUSINESS
Lonzo Coleman
DIRECTOR DDIVERSITY
Raymond Wood
Managing Chairman
Benjamin KovlerDIRECTOR AMEDICAL
Jack McCue, MD
CEORobert George
BO
AR
D
ChairmanPeter Kadens
Chief Medical Officer
Jack McCue, MD
DIRECTOR BPHARMACIST
Jillian Dura, PharmD, CNMT
Patient Education + Advocacy
DirectorDeborah Berlekamp,
PharmD
Marketing + Public
Relations Manager
Information Technology Manager
Security DirectorMichael Dobeck
See Operations Org Chart on following page
Human Resources Director
Diversity+ InclusionManager
Accounting Assistant
Regulatory Compliance
DirectorMildred
Forbes Beal, JD
Gov’t Relations
Asst
Security Manager
Security Personnel
Occupational Health + Safety
Manager
AKE = Associate Key EmployeeDKE = Dispensary Key EmployeeDSE = Dispensary Support Employee
Chief Information
OfficerOPEN
Chief Financial Officer
Patricia Jamieson
Chief Operating OfficerAnthony
Georgiadis
Chief Compliance Officer
Dina Rollman, JD
Chief Legal Officer
Bret Kravitz, JD
Chief Diversity + Community
Outreach OfficerEugene Monroe
Chief Security Officer
Terrance Gainer, JD
Operations DirectorAnthony
Makarich, PharmD
AKE AKE
AKE AKE
AKE AKE
AKE
DKEAKE
DSE
DKE
AKE AKE AKE AKE AKE AKEAKEAKE
Each individual is at least twenty-one years of age, per 3796:6-2-09(C).
TRADE SECRET
Each individual is at least twenty-one years of age, per 3796:6-2-09(C).
TABLE OF ORGANIZATION AND CONTROL– OPERATIONS
CEORobert George
Chief Compliance
OfficerDina Rollman, JD
Chief Security OfficerTerrance
Gainer, JD
Chief Information
OfficerOPEN
Chief Medical Officer
Jack McCue, MD
Chief Financial OfficerPatricia
Jamieson
Chief Diversity + Community
Outreach OfficerEugene Monroe
Chief Operating OfficerAnthony
Georgiadis
Patient Education + Advocacy
DirectorDeborah
Berlekamp, PharmD Dispensary
ManagerAnnie Tran,
PharmD
Maintenance Manager
Inventory Manager
Lead Patient Care
Specialist
Patient Care Specialists
Patient Intake/
Receptionist
Assistant Dispensary Manager
Pharmacist
Security Director
Michael Dobeck
Security Manager
Security Personnel
Quality Manager
Maintenance Technicians
= At DispensaryDR = Designated RepresentativeAKE = Associate Key EmployeeDKE = Dispensary Key EmployeeDSE = Dispensary Support Employee
Operations DirectorAnthony
Makarich, PharmD
Human Resources Director
Diversity + InclusionManager
Occupational Health + Safety
Manager
Chief Legal Officer
Bret Kravitz, JD
AKE AKE AKE AKE AKE AKE AKE AKE
AKE
DKE
DSE DR+DKE DSE DSEDKE
DKEDSE DSE
DSE
DSE DSE
DKE AKE
TRADE SECRET
Business Plan(Capital Requirements)
Item 1 of 2
C-5.1 Type of Capital
C-5.2 Source of Capital
C-5.3 Name and Address of financial institution
C-5.4 Account Number
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for thefirst year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3).The total amount of liquid assets must be no less than $250,000. Provide unredacted documentationfrom the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution tosupport the capital requirements. (ORC 3796:6-2-02)
Cash
Applicant checking account
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5.1_Capital Requirements Redacted DRL.pdfNOTE: This applicant uploaded document is the next 13 page(s) of this document.
Ohio Board of Pharmacy Attn: Ohio Medical Marijuana Control Program 77 South High Street, 17th Floor Columbus, OH 43215 Redacted Version of Question C-5.5 Medical Marijuana Dispensary Applicant: Application Property Address: Cuyahoga County Parcel Number 311-18-088, approximately 18607-18609 Detroit Ave. Extention Lakewood, OH 44107 In accordance with Question C-5.5 of the Ohio Medical Marijuana Dispensary Application, issued by the Ohio Board of Pharmacy, below are the following documents enclosed herein for your review:
1. Illustration that the Applicant has adequate liquid assets to cover all expenses and costs for the first year of operation as indicated in the dispensaries proposed Business Startup Plan (Question C3). This information is provided pursuant to Question C-5.5 and FAQ #290. If this information cannot be evaluated as part of Applicant’s dispensary application, please ignore and refer solely to #2-8 listed below and enclosed.
2. Bank Statement from Applicant’s Financial Institution reflecting a bank account balance of $10,208,028.57, dated October 31, 2017.
3. Letter from Applicant’s Financial Institution, attesting to Applicant’s current bank account balance of $10,208,028.57, dated October 31, 2017.
4. Promissory Note – Line of Credit, from Applicant’s Lender reflecting an immediate line of credit of $5,000,000, dated November 9, 2017.
5. Bank Statement from Applicant’s Lender’s Financial Institution reflecting a bank account balance of $5,533,103.00, dated October 31, 2017.
6. Letter from Applicant’s Lender’s Financial Institution, attesting to Lender’s current bank account balance of $5,533,103.00, dated October 31, 2017.
7. Letter from Applicant’s CPA (Scott A. Moses, CPA at Kelman & Moses) certifying Applicant’s $15.2 million of liquid assets, dated October 31, 2017.
8. Applicant’s Pledge of Liquid Capital, sign and notarized as of November 13, 2017.
LIQUID ASSETS Applicant has $15.2 million in liquid assets ready to deploy in Ohio for its dispensary operations and a sound and proven spending plan that will allow it to become operational in 6 months (per 3796:6-2-04). Applicant’s $15.2 million in liquid assets consists of the following:
• $10.2 million of cash in its checking account. o 10/31/17 WashingtonFirst Bank checking account statement attached. o Letter from WashingtonFirst Bank attached.
• $5.0 million line of credit with that can be drawn by Applicant at any time. o Executed line of credit between Applicant and attached. o 10/31/17 FVCBank checking account statement attached. o Letter from FVCBank attached.
Applicant has also included an executed letter from its CPA affirming its $15.2 million in liquid assets for its Ohio dispensary operations. START UP PLAN Operating a medical marijuana dispensary requires substantial capital. Applicant’s founders have successfully started medical marijuana dispensaries in 5 highly regulated medical marijuana markets including . Applicant understands that having a well-capitalized business with substantial liquid assets positions it for success. Applicant has learned from its experience in other markets that new medical marijuana markets sometimes bring growing pains, surprises and potentially delays that may require additional liquid assets than initially anticipated. Applicant is committed to having sufficient liquid assets to weather any storm that may arise in the Ohio medical marijuana market. Applicant’s liquid assets of $15.2 million are more than adequate to cover the $1.2 million in expenses and costs it expect to incur as part of its business startup plan, as highlighted below.
• $30,000 for year 1 rent expense for the land for Applicant’s dispensary facility. • $700,000 for build-out of Applicant’s dispensary facility, including architectural, design, and
permitting fees ($40,000), construction / general contractor expenses ($525,000), security and surveillance equipment and installation ($75,000), and furniture, fixtures and equipment ($60,000).
• $80,000 for Board of Pharmacy fees including certificate of operation fees ($70,000) and key employee fees ($10,000).
• $400,000 for operating expenses for the first twelve months. Applicant’s $1.2 million spending plan provides it with an additional $14.0 million in liquid assets, substantial capital for four other dispensary locations, if awarded such additional licenses. In addition, Applicant’s liquid asset cushion of $14.0 million provides it with the capital needed to withstand unexpected surprises and delays, while aggressively pursuing commencement of operations within six months.
Please see below for a detailed breakdown of all expenses and costs Applicant estimates it will incur as part of its startup plan.
DISPENSARY START UP EXPENSES - LAKEWOOD
TOTALEstimated Dates Mar - Aug '18 Sept '18 - Feb '19 Mar '18 - Feb '19
Months 1-6 Months 7-12 Months 1-12Phase Construction / Operating ALL PHASES
Hiring / TrainingRent Expense - LANDYear 1 LAND Rent Expense $15,000 $15,000 $30,000
Facility Build-outArchitectural, Design, Permitting $40,000 $0 $40,000Construction / General Contractor $525,000 $0 $525,000Security and Surveillance Equipment $75,000 $0 $75,000Furniture, Fixtures and Equipment $60,000 $0 $60,000
Total Facility Build-out $700,000 $0 $700,000
Department of Pharmacy Fees Certificate of Operation Fees $70,000 $0 $70,000 Dispensary Employee Fees $7,000 $3,000 $10,000Total Department of Pharmacy Fees $77,000 $3,000 $80,000
Operating ExpensesCommunity Engagement $10,000 $10,000 $20,000Recruiting $15,000 $7,000 $22,000Employee Training $20,000 $10,000 $30,000Payroll / Taxes $75,000 $145,000 $220,000Insurance $6,000 $6,000 $12,000Legal $3,000 $3,000 $6,000Marketing $3,000 $9,000 $12,000Security Monitoring $6,000 $18,000 $24,000Inventory Software $6,000 $12,000 $18,000Other $16,000 $20,000 $36,000
Total Operating Expenses $160,000 $240,000 $400,000
Aggregate Spend $952,000 $258,000 $1,210,000% of $15.2 Million Liquid Assets 8%
RENT EXPENSE If awarded a dispensary permit, Applicant intends to rent the land for its dispensary facility; year 1 land rent equals $30,000. DISPENSARY BUILD-OUT Applicant intends to spend $700,000 on the build-out of its dispensary facility. Applicant’s $700,000 estimate includes including architectural, design, and permitting fees ($40,000), construction / general contractor expenses ($525,000), security and surveillance equipment and installation ($75,000), and furniture, fixtures and equipment ($60,000). Applicant’s experience opening medical marijuana dispensaries in other heavily regulated medical markets gives it confidence that it has the proper vendor contracts and other important industry relationships necessary to execute its plan. Architectural, design, permitting Applicant estimates it will spend $40,000 on the finalization of its architectural and design plans so that they are ready for permitting as well as the cost associated with construction permitting. Construction / general contractor expenses Applicant estimates it will spend $525,000 on general contractor and construction fees associated with the build-out of its dispensary facility. Included in this estimate is general sitework, concrete, doors and windows, electrical, finishes, mechanical and allowances. Applicant has engaged a highly-respected, Ohio-based GC to spearhead the design-build process and has already developed a construction plan with its GC that will allow Applicant to complete construction and commence operations in less than six months. Security and Surveillance Equipment and Installation Applicant has budgeted $75,000 for the procurement of security and surveillance equipment and installation of its equipment at its dispensary. Applicant has ensured that its security and surveillance equipment provider contemplated the Board of Pharmacy’s regulations when providing Applicant with a quote. Applicant understands how important security and surveillance equipment is with assisting it with medical marijuana storage, inventory management, and the prevention of medical marijuana diversion. Furniture, Fixtures and Equipment Applicant has budgeted $60,000 for various furniture, fixtures and equipment including millwork, various technology related expenses (software, computers, server, etc.), furniture, lighting, wall décor and other miscellaneous items. BOARD OF PHARMACY FEES Applicant has budgeted $70,000 for its certificate of operation fees and $10,000 for applications associated with associated key employees, key employees, and associate employees. Applicant understands that these fees must be renewed biennially in the same amounts.
OPERATING EXPENSES FOR FIRST TWELVE MONTHS Applicant has budgeted $400,000 in operating expenses for the first twelve months. While Applicant is working on the construction of its facility, it will also be creating the necessary administrative infrastructure to support a medical marijuana dispensary. The compliance heavy nature of operating a medical marijuana dispensary requires it to invest heavily in recruiting, staffing, and training prior to becoming operational. Applicant’s $400,000 budget for operating expenses includes:
• Community Engagement: $20,000 • Recruiting: $22,000 • Employee Training: $30,000 • Payroll / Taxes: $220,000 • Insurance: $12,000 • Legal: $6,000 • Marketing: $12,000 • Security Monitoring: $24,000 • Inventory Software: $18,000 • Other: $36,000
Applicant’s $220,000 payroll and tax budget provides it with sufficient resources to staff and train its facility employees, among other things, on the storage of medical marijuana products, inventory management, recordkeeping and medical marijuana diversion prevention. BANKING RELATIONSHIP To execute its startup plan and run its business efficiently, Applicant has secured a banking relationship with an established financial institution. Based on Applicant’s attention to the U.S Department of Justice “Cole Memo,” strict compliance with U.S. Treasury’s “FinCen” and secured bank’s due diligence on Applicant, this financial institution will allow Applicant to accept debit cards from customers, checks from customers, run payroll efficiently and optimize the safety of all involved with accounts payable and accounts receivable. This relationship sets Applicant further apart from others and further points to a significant likelihood of success. Applicant maintains bank accounts at several banking institutions around the country and does so in a safe, compliant and transparent manner. Applicant looks forward to maintaining high standards of banking compliance in the Ohio medical marijuana industry. SUMMARY Applicant has liquid assets of $15.2 million, a sound and conservative startup plan, and experience starting medical marijuana dispensaries in five other heavily regulated medical marijuana markets
. All of these factors position Applicant to be poised for success in Ohio if provided the opportunity to operate a medical marijuana dispensary.
First Virginia Community Bank11325 Random Hills RoadFairfax VA 22030Telephone: 703-436-3840
Page: 1
Account Number: Statement Date: 10/31/17 Checks/Items Enclosed: 1
ME
Celebrating Ten Years - Thank You for Believing in Us!
BUSINESS CHECKING Acct
Beginning Balance 10/01/17 3,753,103.00 Deposits / Misc Credits 11 1,780,000.00 Withdrawals / Misc Debits 0 .00 ** Ending Balance 10/31/17 5,533,103.00 ** Service Charge .00
Average Balance 4,612,941 Average Collected Balance 4,612,941 Minimum Balance 3,753,103 Enclosures 1
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Business Plan(Capital Requirements)
Item 2 of 2
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)
Line of Credit
Third-party checking account
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5.1_Capital Requirements Redacted DRL.pdfNOTE: This applicant uploaded document is the next 13 page(s) of this document.
Ohio Board of Pharmacy Attn: Ohio Medical Marijuana Control Program 77 South High Street, 17th Floor Columbus, OH 43215 Redacted Version of Question C-5.5 Medical Marijuana Dispensary Applicant: Application Property Address: Cuyahoga County Parcel Number 311-18-088, approximately 18607-18609 Detroit Ave. Extention Lakewood, OH 44107 In accordance with Question C-5.5 of the Ohio Medical Marijuana Dispensary Application, issued by the Ohio Board of Pharmacy, below are the following documents enclosed herein for your review:
1. Illustration that the Applicant has adequate liquid assets to cover all expenses and costs for the first year of operation as indicated in the dispensaries proposed Business Startup Plan (Question C3). This information is provided pursuant to Question C-5.5 and FAQ #290. If this information cannot be evaluated as part of Applicant’s dispensary application, please ignore and refer solely to #2-8 listed below and enclosed.
2. Bank Statement from Applicant’s Financial Institution reflecting a bank account balance of $10,208,028.57, dated October 31, 2017.
3. Letter from Applicant’s Financial Institution, attesting to Applicant’s current bank account balance of $10,208,028.57, dated October 31, 2017.
4. Promissory Note – Line of Credit, from Applicant’s Lender reflecting an immediate line of credit of $5,000,000, dated November 9, 2017.
5. Bank Statement from Applicant’s Lender’s Financial Institution reflecting a bank account balance of $5,533,103.00, dated October 31, 2017.
6. Letter from Applicant’s Lender’s Financial Institution, attesting to Lender’s current bank account balance of $5,533,103.00, dated October 31, 2017.
7. Letter from Applicant’s CPA (Scott A. Moses, CPA at Kelman & Moses) certifying Applicant’s $15.2 million of liquid assets, dated October 31, 2017.
8. Applicant’s Pledge of Liquid Capital, sign and notarized as of November 13, 2017.
LIQUID ASSETS Applicant has $15.2 million in liquid assets ready to deploy in Ohio for its dispensary operations and a sound and proven spending plan that will allow it to become operational in 6 months (per 3796:6-2-04). Applicant’s $15.2 million in liquid assets consists of the following:
• $10.2 million of cash in its checking account. o 10/31/17 WashingtonFirst Bank checking account statement attached. o Letter from WashingtonFirst Bank attached.
• $5.0 million line of credit with that can be drawn by Applicant at any time. o Executed line of credit between Applicant and attached. o 10/31/17 FVCBank checking account statement attached. o Letter from FVCBank attached.
Applicant has also included an executed letter from its CPA affirming its $15.2 million in liquid assets for its Ohio dispensary operations. START UP PLAN Operating a medical marijuana dispensary requires substantial capital. Applicant’s founders have successfully started medical marijuana dispensaries in 5 highly regulated medical marijuana markets including . Applicant understands that having a well-capitalized business with substantial liquid assets positions it for success. Applicant has learned from its experience in other markets that new medical marijuana markets sometimes bring growing pains, surprises and potentially delays that may require additional liquid assets than initially anticipated. Applicant is committed to having sufficient liquid assets to weather any storm that may arise in the Ohio medical marijuana market. Applicant’s liquid assets of $15.2 million are more than adequate to cover the $1.2 million in expenses and costs it expect to incur as part of its business startup plan, as highlighted below.
• $30,000 for year 1 rent expense for the land for Applicant’s dispensary facility. • $700,000 for build-out of Applicant’s dispensary facility, including architectural, design, and
permitting fees ($40,000), construction / general contractor expenses ($525,000), security and surveillance equipment and installation ($75,000), and furniture, fixtures and equipment ($60,000).
• $80,000 for Board of Pharmacy fees including certificate of operation fees ($70,000) and key employee fees ($10,000).
• $400,000 for operating expenses for the first twelve months. Applicant’s $1.2 million spending plan provides it with an additional $14.0 million in liquid assets, substantial capital for four other dispensary locations, if awarded such additional licenses. In addition, Applicant’s liquid asset cushion of $14.0 million provides it with the capital needed to withstand unexpected surprises and delays, while aggressively pursuing commencement of operations within six months.
Please see below for a detailed breakdown of all expenses and costs Applicant estimates it will incur as part of its startup plan.
DISPENSARY START UP EXPENSES - LAKEWOOD
TOTALEstimated Dates Mar - Aug '18 Sept '18 - Feb '19 Mar '18 - Feb '19
Months 1-6 Months 7-12 Months 1-12Phase Construction / Operating ALL PHASES
Hiring / TrainingRent Expense - LANDYear 1 LAND Rent Expense $15,000 $15,000 $30,000
Facility Build-outArchitectural, Design, Permitting $40,000 $0 $40,000Construction / General Contractor $525,000 $0 $525,000Security and Surveillance Equipment $75,000 $0 $75,000Furniture, Fixtures and Equipment $60,000 $0 $60,000
Total Facility Build-out $700,000 $0 $700,000
Department of Pharmacy Fees Certificate of Operation Fees $70,000 $0 $70,000 Dispensary Employee Fees $7,000 $3,000 $10,000Total Department of Pharmacy Fees $77,000 $3,000 $80,000
Operating ExpensesCommunity Engagement $10,000 $10,000 $20,000Recruiting $15,000 $7,000 $22,000Employee Training $20,000 $10,000 $30,000Payroll / Taxes $75,000 $145,000 $220,000Insurance $6,000 $6,000 $12,000Legal $3,000 $3,000 $6,000Marketing $3,000 $9,000 $12,000Security Monitoring $6,000 $18,000 $24,000Inventory Software $6,000 $12,000 $18,000Other $16,000 $20,000 $36,000
Total Operating Expenses $160,000 $240,000 $400,000
Aggregate Spend $952,000 $258,000 $1,210,000% of $15.2 Million Liquid Assets 8%
RENT EXPENSE If awarded a dispensary permit, Applicant intends to rent the land for its dispensary facility; year 1 land rent equals $30,000. DISPENSARY BUILD-OUT Applicant intends to spend $700,000 on the build-out of its dispensary facility. Applicant’s $700,000 estimate includes including architectural, design, and permitting fees ($40,000), construction / general contractor expenses ($525,000), security and surveillance equipment and installation ($75,000), and furniture, fixtures and equipment ($60,000). Applicant’s experience opening medical marijuana dispensaries in other heavily regulated medical markets gives it confidence that it has the proper vendor contracts and other important industry relationships necessary to execute its plan. Architectural, design, permitting Applicant estimates it will spend $40,000 on the finalization of its architectural and design plans so that they are ready for permitting as well as the cost associated with construction permitting. Construction / general contractor expenses Applicant estimates it will spend $525,000 on general contractor and construction fees associated with the build-out of its dispensary facility. Included in this estimate is general sitework, concrete, doors and windows, electrical, finishes, mechanical and allowances. Applicant has engaged a highly-respected, Ohio-based GC to spearhead the design-build process and has already developed a construction plan with its GC that will allow Applicant to complete construction and commence operations in less than six months. Security and Surveillance Equipment and Installation Applicant has budgeted $75,000 for the procurement of security and surveillance equipment and installation of its equipment at its dispensary. Applicant has ensured that its security and surveillance equipment provider contemplated the Board of Pharmacy’s regulations when providing Applicant with a quote. Applicant understands how important security and surveillance equipment is with assisting it with medical marijuana storage, inventory management, and the prevention of medical marijuana diversion. Furniture, Fixtures and Equipment Applicant has budgeted $60,000 for various furniture, fixtures and equipment including millwork, various technology related expenses (software, computers, server, etc.), furniture, lighting, wall décor and other miscellaneous items. BOARD OF PHARMACY FEES Applicant has budgeted $70,000 for its certificate of operation fees and $10,000 for applications associated with associated key employees, key employees, and associate employees. Applicant understands that these fees must be renewed biennially in the same amounts.
OPERATING EXPENSES FOR FIRST TWELVE MONTHS Applicant has budgeted $400,000 in operating expenses for the first twelve months. While Applicant is working on the construction of its facility, it will also be creating the necessary administrative infrastructure to support a medical marijuana dispensary. The compliance heavy nature of operating a medical marijuana dispensary requires it to invest heavily in recruiting, staffing, and training prior to becoming operational. Applicant’s $400,000 budget for operating expenses includes:
• Community Engagement: $20,000 • Recruiting: $22,000 • Employee Training: $30,000 • Payroll / Taxes: $220,000 • Insurance: $12,000 • Legal: $6,000 • Marketing: $12,000 • Security Monitoring: $24,000 • Inventory Software: $18,000 • Other: $36,000
Applicant’s $220,000 payroll and tax budget provides it with sufficient resources to staff and train its facility employees, among other things, on the storage of medical marijuana products, inventory management, recordkeeping and medical marijuana diversion prevention. BANKING RELATIONSHIP To execute its startup plan and run its business efficiently, Applicant has secured a banking relationship with an established financial institution. Based on Applicant’s attention to the U.S Department of Justice “Cole Memo,” strict compliance with U.S. Treasury’s “FinCen” and secured bank’s due diligence on Applicant, this financial institution will allow Applicant to accept debit cards from customers, checks from customers, run payroll efficiently and optimize the safety of all involved with accounts payable and accounts receivable. This relationship sets Applicant further apart from others and further points to a significant likelihood of success. Applicant maintains bank accounts at several banking institutions around the country and does so in a safe, compliant and transparent manner. Applicant looks forward to maintaining high standards of banking compliance in the Ohio medical marijuana industry. SUMMARY Applicant has liquid assets of $15.2 million, a sound and conservative startup plan, and experience starting medical marijuana dispensaries in five other heavily regulated medical marijuana markets
. All of these factors position Applicant to be poised for success in Ohio if provided the opportunity to operate a medical marijuana dispensary.
First Virginia Community Bank11325 Random Hills RoadFairfax VA 22030Telephone: 703-436-3840
Page: 1
Account Number: Statement Date: 10/31/17 Checks/Items Enclosed: 1
ME
Celebrating Ten Years - Thank You for Believing in Us!
BUSINESS CHECKING Acct
Beginning Balance 10/01/17 3,753,103.00 Deposits / Misc Credits 11 1,780,000.00 Withdrawals / Misc Debits 0 .00 ** Ending Balance 10/31/17 5,533,103.00 ** Service Charge .00
Average Balance 4,612,941 Average Collected Balance 4,612,941 Minimum Balance 3,753,103 Enclosures 1
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Business Plan(Business History and Experience)
Item 1 of 3
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
T.
George
Officer
Corporate Management Group
18605 Detroit Ave. Lakewood, OH 44107
YES
2004-present
Business Plan(Business History and Experience)
Item 2 of 3
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
No response provided by applicant
George
Owner
Apex Transit Solutions
3950 Prospect Ave. East, Cleveland, OH 44115
YES
2013-present
Business Plan(Business History and Experience)
Item 3 of 3
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
Anthony
No response provided by applicant
Giardini
Owner
Giardini, Poplar & Mason, LLC
520 Broadway, Third Floor, Lorain, OH 44052
YES
2007-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
PETER KADENS AND BEN KOVLER: OWNERS WITH COMPREHENSIVE EXPERIENCEOPERATING MEDICAL MARIJUANA BUSIENSSES.
Kadens and Kovler founded GTI in 2014, and it now holds 19 licenses to operate medical marijuanacultivation, processing and dispensary facilities in 5 highly-regulated states: Illinois, Pennsylvania,Maryland, Massachusetts, and Nevada, as follows:
• Illinois: 4 dispensary licenses, 2 cultivation/processing licenses• Pennsylvania: 3 dispensary licenses, 1 cultivation/processing license• Maryland: 2 dispensary licenses, 1 processing license• Massachusetts: 2 vertically integrated licenses (cultivation/processing/dispensary)• Nevada: 2 dispensary licenses, 1 cultivation license, 1 processing licenseNONE OF GTI’S MEDICAL MARIJUANA BUSINESSES HAVE EVER FACED ADMINISTRATIVEDISCIPLINE.
Kovler serves as CEO of GTI’s Illinois business. Under the leadership of Kovler, GTI Illinoisaccomplished the construction and build-out of two 45,000 square foot cultivation/processing facilitiesin under 6 months, with both passing building code and marijuana regulatory inspections. Throughthoughtful planning and close management of the construction process, Kovler made GTI Illinois thefirst cultivator to market with medical marijuana to sell to dispensaries in Illinois.
While managing the cultivation facility construction, Kovler simultaneously oversaw the interior buildoutof GTI Illinois’ first medical marijuana dispensary, The Clinic Mundelein, and managed scheduledmilestones to prepare for operations, guaranteeing that the dispensary was ready to open for businesson the first day that Illinois allowed retail medical marijuana sales. GTI Illinois now owns and operates4 dispensaries that have more than 10% retail market share, serving thousands of Illinois patientsevery month.
As CEO, Kovler has overseen the implementation of seed-to-sale inventory tracking and robustsecurity and surveillance systems at the wholesale and retail level.
Kadens serves as CEO for GTI’s 4 other state markets. Kadens has overseen the hiring of over 150individuals throughout its facilities to date and once all of the businesses are up and running, theirfacilities will have created hundreds more jobs. Kadens oversaw the interior buildout andcommencement of operations of 2 dispensaries in Nevada (RISE Carson City and RISE SpanishSprings), which serve thousands of patients a month. He is currently overseeing the interior buildout ofGTI’s facilities in Maryland, Pennsylvania, and Massachusetts and expects them to be operationalbeginning in December 2017.
Kadens is one of only five cannabis industry CEOs selected to serve on the Board of Directors of the
Marijuana Policy Project (MPP), the nation's leading organization focused solely on federal and state-wide marijuana policy reform.
Kadens and Kovler’s expertise in creating and implementing business plans and financial plans havebeen key to GTI’s success. Kadens and Kovler have raised over $80 million from private investors inthe past 3 years by developing and demonstrating sound business plans. They have assembledexperienced boards of directors to help achieve GTI’s financial objectives, have relied on conservativebudget assumptions, careful capital allocations, and a focus on community impact to create asuccessful, long term enterprise.
Kadens and Kovler will use their medical marijuana business expertise to ensure the success of theOhio dispensary operations.
ROBERT GEORGE – A Seasoned Business OperatorOver the past 13 years, George – the founder and CEO of Corporate Management Group (CMG) – hasbeen operating 18 restaurants in 2 states that have a combined gross revenue of over $60 million. AsCEO, George has acquired many skills that will benefit the Ohio dispensary operations:
• Experience managing a large workforce.• Experience forecasting, acquiring, and tracking inventory.• Adherence to health and safety regulations, including OSHA, ADA, and food safety guidelines.• Maintaining facilities and equipment in a clean and orderly condition.• Receiving, inspecting, transporting, segregating, and storing supplies in a sanitary manner.• Maintaining secure cash management and secure operations.• Investing in his employees to promote a good workplace culture and reduce turnover.• Maintaining good relationships within the community.
George has also focused on rehabilitating historic buildings, in coordination with state and federalgovernments. George began acquiring commercial and residential properties in 2007, and now ownsover 2 million square feet of commercial and residential properties.
None of George’s or CMG’s businesses have ever faced administrative discipline.
ANTHONY GEORGIADISAnthony Georgiadis is a seasoned entrepreneur and operator. In 2005, he purchased Wendover ArtGroup, a manufacturer of wall décor. At the time, it was producing approximately 150 pictures a daywith 25 employees.
Over the course of 11 years, Georgiadis grew the company through consistent reinvestment in people,process and technology. By 2015 the company had 350 employees, a blue-chip customer base, andwas producing over 5,000 units a day. Under his leadership, Wendover Art Group:• Constructed a 124,000-square foot state-of-the-art highly automated manufacturing facility.• Grew the labor force by 14x, from 25 to 350 employees.• Grew annual revenue by 10x, from under $5 million to over $50 million.• Scaled the supply chain and production capacity by 32x, increasing daily yield from 150 units/day to5,000 units/day.• Grew the customer base from 5 to 5,000, including expanding into large retail, hospitality, assistedliving and independent furniture stores.• Grew Wendover into the leading manufacturer of artwork and mirrors in the United States.Georgiadis also:• Developed and implemented Wendover’s financial and business plans, which, when audited, proved
to have impeccable financial and inventory controls.• Implemented and maintained a state-of-the-art Enterprise Resource Planning (ERP) and inventorytracking system to track the company’s $4 million of inventory on a real-time basis.• Oversaw the installation and maintenance of a security system customized by Avigilon, one of theleading security providers in North America, to protect the company’s inventory, which included 24/7security and monitoring.
During the entirety of Georgiadis’s 11-year tenure as owner and COO of Wendover (2005 - 2015), itnever faced any administrative discipline of any kind.
Georgiadis joined GTI in 2015 and currently oversees GTI’s dispensary operations in Nevada.
ANDREW GROSSMANAndy Grossman is an entrepreneur and business executive with 20 years of experience in the highly-regulated hedge fund industry. In 2011, Grossman co-founded LG Capital, an event-driven hedge fundwith $13 million of capital, which grew to a peak of $350 million over a 4-year period. Grossman soldLG in 2015. Grossman built LG Capital’s infrastructure, implemented the procedures and processes tooperate the business, managed the company’s annual audit, and oversaw regulatory complianceefforts with the Securities and Exchange Commission and State of Maryland.
During the entirety of Grossman’s 4-year tenure at LG, it never faced any administrative discipline ofany kind.
Grossman joined GTI in 2015 and currently oversees GTI’s operational start-up of medical marijuanaprocessing and dispensary facilities in Maryland.
EUGENE MONROEEugene Monroe is a University of Virginia graduate and 1st round 8th overall selection in the 2009 NFLDraft. Monroe was traded to the Baltimore Ravens in 2013, retired in 2016 and became the first activeNFL player to speak in favor of medical marijuana research and marijuana policy reform. Eugeneserves as a board member of the NFLPA Pain Management Committee and the HealthyUNowFoundation (supporting the Autism community), and is the Athletic Ambassador for Doctors forCannabis Regulation.
Since 2015, Monroe has served as GTI’s national ambassador for educating communities on howmedical marijuana can be used as a safe, non-addictive alternative to prescription opioids. He will leadand oversee GTI’s efforts to recruit, hire, train, and educate minorities in Ohio, as he has done in otherstates for GTI.
ANTHONY GIARDINIAnthony Giardini is an Ohio-licensed attorney who has owned and managed his own law practice forthe past 10 years. He has been practicing law for almost 42 years. He also serves as the managingmember of 3 different real estate businesses that own and lease residential and commercial realestate.
Giardini also volunteers his services and expertise, and currently serves as a member of the LorainCounty Board of Elections (12 years) where he sets budgets, runs elections, hires staff and overseesother governmental functions, and serves as a Board member for the Lorain County Community ActionAgency that runs the local Head Start program and provides various social services for adults.
JOSEPH THOMAS GEORGE
Joseph George is an experienced Ohio-licensed attorney, mediator/magistrate and a successfulbusiness operator. Since 2014, he has served as tax mediator and tax magistrate for the City ofBrookpark, Ohio. George also handles all housing and building mediations for the City.
In 2012, George founded Apex Transit Solutions, a wheelchair transportation company that is thetransportation provider to Louis Stokes Cleveland VA Medical Center and various nursing homefacilities. He continues to grow and oversee operations.
From 2009 through 2015, George worked in private practice as an attorney handling a wide variety ofcivil and criminal matters.
George is involved in a number of charitable endeavors including Awakening Angels, a non-profitorganization supporting research to mitigate the effects of Down syndrome on individuals of all ages.George also gives back to the community by coaching high school football in the greater Clevelandarea.
During the entirety of Joseph George’s legal career and tenure as a business owner and operator,George and his businesses have never faced any administrative discipline of any kind.
Operations Plan(Dispensary Oversight)
D-1.1 By selecting "Yes", the Applicant attests that it will appoint a designated representativeresponsible for the oversight, supervision and control of operations of the medical marijuanadispensary. When there is a change in the appointed designated representative, the Applicant willnotify the State Board of Pharmacy within 10 business days of appointment. OAC 3796:6-3-05 YES
1.2.3.4.5.6.7.8.
Operations Plan(Security and Surveillance )
D-2.1 By checking “Yes,” the Applicant attests that it is able to continuously maintain effective security,surveillance and accounting control measures to prevent diversion, abuse and other illegal conductregarding medical marijuana and medical marijuana products.
D-2.2 Please provide a summary of the Applicant's proposed security and surveillance equipment andmeasures that will be in place at the proposed facility and site. These measures should cover, but arenot limited to, the following:
General overview of the equipment, measures and procedures to be usedAlarm systemsSurveillance systemSurveillance storageRecording capabilityRecords retentionPremises accessibilityInspection/servicing/alteration protocols
Please reference OAC 3796:6-3-16 for more information.
D-2.2.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-2.2. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
YES
This response has been entirely redacted
Uploaded Document Name: D-2.2.1_Security Equipment and Floor Plans DRL.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
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
NOTE: This applicant uploaded document is the next 3 page(s) of this document.
TRADE SECRET
D-5.5.1 Dispensing of Product Attachment Page 1 of 3
SAMPLE LABELS
Patient Label – Placed on package without obscuring any information provided by cultivator/processor
Aliquot Transport Container Label
LABEL NOT TO SCALE
TRADE SECRET
D-5.5.1 Dispensing of Product Attachment Page 2 of 3
SAMPLE TRANSPORT CONTAINERS FOR ALIQUOTS
For Plant Material, Edibles, Transdermal Patches, Dissolving Strips
For Capsules/Tablets
For Liquids
For Creams
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
TRADE SECRET
SECURITY AND INFRASTRUCTURE
GENERAL WAITING AREA LIBRARY
1 of 41 of 4
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
9:00 a.m. - 7:00 p.m.
Patient Care(Patient Information)
E-5.1 By selecting "Yes", the Applicant attests that it will post a sign directing patients and caregiverswith medical marijuana inquiries or adverse reactions to the toll-free hotline established by the StateBoard of Pharmacy. OAC 3796:6-3-15
E-5.2 By selecting "Yes", the Applicant attests that it will make information regarding the use andpossession of medical marijuana available to patients and caregivers. The Applicant agrees to submitall such information to the State Board of Pharmacy prior to being provided to patients and caregivers. OAC 3796:6-3-15
YES
YES
Attestations and Acknowledgements(Attestations and Acknowledgements)
F-1.1 Fill out and attach the “Trade Secret Form” to Question F-1.1, specifying the question and / orattachment references of the application submission that are exempt from disclosure under Ohio publicrecords law and articulate how the information meets the definition of “trade secret” under OhioRevised Code section 1333.61(D). If no material is designated as trade secret information, a statementof “None” should be listed on the form. Uploaded Document Name: F-1.1_ Trade Secret Form.pdfNOTE: This applicant uploaded document is the next 15 page(s) of this document.
Page 1 of 15
STATEMENT SUPPORTING TRADE SECRET NOTIFICATION FORM GTI Ohio, LLC (“Applicant”) has designated three categories of application information as trade secrets to be protected from disclosure under Ohio Revised Code Section 1333.61 et seq. The first is Applicant’s Business Plan (Section C). The second is Applicant’s Operations Plan (Section D). The third is Applicant’s Patient Care Plan (Section E). The sections identified, and justifications for those specific designations, are set forth in this statement and in the table below. The trade secret justifications below, taken together with this supporting statement (“Supporting Statement”), demonstrate that all of Sections C, D, and E of Applicant’s dispensary application should be treated as exempt from public disclosure. Applicant respectfully requests that all of the sections identified below be treated with “Trade Secret” status and that these sections, in their entirety, be exempt from disclosure to the public.
Pursuant to Ohio Revised Code section 1333.61(D), Ohio has adopted the Federal Uniform Trade Secrets Act. Ohio Revised Code section 1333.61(D) defines a trade secret as information, including business information or plans or financial information, that (1) derives independent economic value, actual or potential, from not being generally known to, and being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use and (2) is the subject of efforts that are reasonable under the circumstances to maintain its secrecy (R.C. § 1333.61(D)).
Applicant has been engaged in the highly competitive medical marijuana industry since 2014. Due to the infancy of the industry, most of the methods, techniques, and processes employed in the industry had to be developed completely from scratch. Applicant has invested substantial sums of money and time into developing proprietary standard operating procedures and best-of-industry practices that are detailed in the information and material contained in Sections C, D, and E of Applicant’s application.
Similarly to Ohio, most states that have legalized medical marijuana have issued a
limited number of medical marijuana licenses making these merit-based bids for licenses highly competitive. Applicants are asked to provide narrative descriptions of their business history, facility plans, operations timelines and procedures, sanitation and safety protocols, storage and transportation methods, inventory management systems, security and surveillance systems community outreach programs, medical advisory boards, etc. In addition to providing detailed descriptions of this proprietary information, Applicant has spent hundreds of hours and considerable financial capital assembling applications in a method and technique that has proven successful in securing state issued medical marijuana licenses in several highly competitive states. Applicant’s success winning competitive bids for licenses has made its technique for successful applications an extremely valuable asset that Applicant has had to protect from multiple FOIA requests from competitors.
The material in Sections C, D, and E of the application have provided, and will
continue to provide, substantial value to Applicant as the methods, plans, and procedures contained in those application sections have led to Applicant receiving licenses in highly
Page 3 of 15
competitive states. Recently, Applicant invested significant time and resources defending the redacted content within its Pennsylvania application from competitors. Thus, disclosure of the sections identified by Applicant would cause unfair competitive harm by giving other applicants for dispensary licenses in future markets (or new applications in existing markets) an unfair peek into Applicant’s winning procedures, methods, and practices. Further, the information contained in Sections C, D, and E of the application are critical to Applicant’s operation of medical marijuana dispensaries and would harm Applicant’s competitive advantage in providing best-in-industry compliance, operations, and patient care in those active markets. I. Ohio Law Exempts All of the Content in Sections C, D, and E of the
Application from Disclosure.
Applicant has invested substantial sums of money and time into all of the information and material contained in Sections C, D, and E – the scored section of the dispensary application. All of the information therein satisfies the six factors established by the Ohio Supreme Court1 to determine whether information warrants trade secret protection:
(1) The information is not known outside the business. All persons that worked on
the application were subject to confidentiality agreements, and all application materials were exclusively shared within this small group of persons.
(2) The extent to which it is known to those inside the business, i.e., by the employees: The information called for in Sections C, D, and E is not known outside a small group of Applicant’s key executives involved in preparing the application and the designated staff who assist in preparation and submission of the application who have all executed confidentiality agreements. Beyond these individuals, no employees, contractors or vendors have access to the information.
(3) The precautions taken by the holder of the trade secret to guard the secrecy of the information: Applicant has applied for medical marijuana licenses in competitive application processes in other states and has consistently asserted exemptions from applicable state law public records acts. Notably, Applicant invested significant time and resources redacting, and defending the redacted content, for its successful Pennsylvania cultivation application. To date, Applicant has never been ordered to disclose its confidential application materials.
(4) The savings effected and the value to the holder in having the information as against competitors: As set forth in this statement, the material in Sections C, D, and E of the application has provided, and will continue to provide, substantial value to Applicant as the methods, plans, and procedures contained in the sections have led to Applicant receiving licenses in highly competitive states. Applicant intends to apply for a processing license in Ohio and apply
1 State ex rel. Plain Dealer v. Ohio Dept. of Ins., 80 Ohio St. 3d 513, 524-525 (1997).
Page 4 of 15
for licenses in other states that hold competitive application processes. Disclosure of the sections identified by Applicant as trade secrets would cause unfair competitive harm by giving other applicants for Ohio licenses, as well as competitors for cultivation, processing or dispensary licenses in other states, an unfair peek into Applicant’s winning procedures, methods, and practices.
(5) The amount of effort or money expended in obtaining and developing the information: As set forth herein, Applicant’s principals have spent years, and millions of dollars developing the information needed to set Applicant’s application apart from other qualified competitors for a dispensary license, including working with architects, security experts, construction companies, accountants, attorneys, consultants and other highly technical third-party advisors.
(6) The amount of time and expense it would take for others to acquire and duplicate the information. Applicant’s principals first participated in a competitive license application process in Illinois in September 2014, more than three years ago. Applicant’s principals were successful in that process, receiving a top score and 3 out of 21 available licenses. In 2017, Applicant received the highest scores in the Commonwealth of Pennsylvania as part of its grower/processor and dispensary application. If a competitor newly entering the industry were to gain access to Applicant’s Ohio application, the competitor would unfairly reap the benefits of years of Applicant’s efforts, and millions of dollars expended by Applicant.
The table below incorporates the foregoing justifications for GTI’s claim that Sections C, D, and E contain competitive commercial information and trade secrets that Ohio law exempts from public disclosure. The requested protections are warranted based on the explanation and authorities cited above which demonstrate the substantial competitive harm that GTI would suffer upon disclosure of its propriety and confidential trade secret information.
(continues on next page)
Page 5 of 15
Question Number Attachment Reference
Justification for Excluding as Trade Secret
A-6.7-11; Prospective Associated Key Employee Details A-6.13-Expertise
n/a This question contains Applicant’s financial information, Applicant’s method for selecting key employees, and Applicant’s method and technique for highlighting employee expertise for a successful application. This information is highly strategic and valuable in nature. If revealed, this information would allow Applicant’s competitors to unfairly adjust their applications, or alter their application strategies, in an attempt to outscore Applicant in future competitions for licenses in Ohio and elsewhere. This will cause substantial harm to GTI’s competitive position and impede its ability to distinguish itself in bids for future licenses. R.C. § 1333.61(D)
C-2.1 Site + Facility Plan C-2.1 Applicant has spent considerable time and expense developing facility plans that allow for Applicant’s successful operation of dispensaries in multiple states. This includes spending considerable sums on architects and real estate experts. Applicant’s method for selecting sites and developing facility plans has allowed Applicant to secure licenses to operate in competitive bids for state-issued licenses. Additionally, if Applicant is selected for a dispensary license, the other licensees would know from the outset how Applicant plans to structure its facility and would be able to copy these plans, thereby harming Applicant’s competitive position in the Ohio market. Revealing Applicant’s answer would also harm Applicant competitively in future applications that request this information as competitors would be able to unfairly utilize Applicant’s method. Applicant is a private company that keeps its facility plans strictly private and access is given only to those individuals who require access for the purpose of applications and actual operation.
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R.C. § 1333.61(D) C-3.1 Business Startup Plan
C-3.1.1
Everything contained in this section goes to the very heart of Applicant’s business. Applicant’s answer to this question includes its process, method, and plan for running an operational dispensary, training employees, ensuring a secure facility, and storing medical marijuana product. The business plan has been in development for over two years, during which time Applicant was operational in other states and using real-time experience to refine its plans. Applicant has also spent over a hundred thousand dollars assembling this Application, as well as a great deal more developing its business and operations strategies over the years. Should a competitor gain access to this information, the competitor would be able to copy Applicant’s plans in Ohio, thereby negating Applicant’s competitive advantage. Competitors could also use this plan on future applications causing substantial harm to Applicant’s ability to distinguish itself in bids for licenses. R.C. § 1333.61(D)
C-3.2 Business Startup Plan for Regulatory Compliance
n/a Everything contained in this answer goes to the very heart of Applicant’s business. Applicant’s process, method, and plan for running a compliant dispensary are derived from years of running operationally compliant dispensaries and considerable legal and subject matter expert expense. Applicant’s method and plan for operating a compliant dispensary has substantial value to competitors who wish to utilize Applicant’s successful method and plan on future applications and impair Applicant’s ability to distinguish itself from the long list of applicants in any given state. Due to Applicant’s success obtaining licenses in other states, Applicant’s plans are highly sought after and have been the subject of FOIA requests that Applicant has successfully contested. R.C. § 1333.61(D)
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C-4.1 Duties, Roles, Responsibilities of Prospective Key Employees
C-4.2 Applicant’s method for staffing and assigning duties, roles, and responsibilities of Applicant’s employees forms part of its “special sauce” for winning licenses in competitive state bids. This information is highly strategic and valuable in nature. Rather than simply stating the employee’s role, this Application, and others, requires a narrative description that forms part of the overall score in competitive bids for licenses. If revealed, this information would give competitors an unfair peak into Applicant’s business plans and application strategy causing substantial harm to Applicant’s ability to distinguish itself in future bids for licenses. R.C. § 1333.61(D)
C-6.9 Prospective Associated Key Employee Background
n/a Applicant’s method for selecting employees and describing their background forms part of Applicant’s “special sauce” for a successful application. An applicant’s employees, and accompanying narrative description, form part of the overall score in highly selective and competitive bids for licenses in Ohio and other states. Applicant has incurred considerable expense assembling a team of subject matter experts and invested over three years of time refining its method for selecting and presenting key employees. If disclosed, competitors would get the opportunity to unfairly adjust their applications, or alter their application strategies, in an attempt to outscore Applicant in future competitions for licenses in Ohio and elsewhere. R.C. § 1333.61(D)
D-2.2 Summary of Security + Surveillance
D-2.2.1 Applicant’s method and procedures for operating a properly secured and monitored facility are derived, in part, from Applicant’s experience successfully operating in other states. Applicant has invested considerable time and expense refining its security and surveillance methods and assembling a team of expert consultants to describe these methods and procedures. This forms part of
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Applicant’s “special sauce” for a successful application. If revealed, this information would cause substantial harm to Applicant’s ability to distinguish itself by highlighting the security and surveillance expertise Applicant refined over three years of operation. R.C. § 1333.61(D)
D-3.3 Receiving Product D-3.3.1 Applicant’s answer to this question is a detailed narrative description of the method Applicant has developed and refined for receiving product at its dispensaries. Applicant’s method for receiving product has been refined over a period of years successfully operating in other states and would cause significant harm to Applicant if disclosed to competitors. If this information is revealed to competitors, competitors would be able to easily duplicate Applicant’s “special sauce” for receiving product on future applications and extinguish the competitive advantage Applicant gained from years refining and developing their method. R.C. § 1333.61(D)
D-4.4 Proper Storage D-4.4.1 This question asks applicants to describe their plan for storage of medical marijuana within the proposed dispensary including oversight, physical security measures, record maintenance, climate control and lighting maintenance, and sanitation. Applicant’s response is a detailed plan for proper storage of medical marijuana at a dispensary that Applicant has created and refined over years of successful dispensary operations in other states. If Applicant is selected for a dispensary license, the other licensees would know from the outset exactly how Applicant stores medical marijuana, harming Applicant’s ability to compete in the Ohio market by eliminating any competitive advantage Applicant has gained from years of operation. Additionally, revealing Applicant’s answer would also harm Applicant’s ability to distinguish itself0 in future applications that request this
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information because competitors will be able to duplicate Applicant’s plan without the considerable cost, time, and effort. R.C. § 1333.61(D)
D-5.5 Dispensing + Labeling
D-5.5.1 This question asks applicants to describe the processes, procedures, and controls regarding the dispensing of medical marijuana, updating the patient record, and product labeling. Applicant’s answer to this question reveals its confidential proprietary internal procedures for ensuring compliant dispensing and labeling that Applicant has created and refined from experience successfully operating in highly regulated states. If Applicant is selected for a dispensary license, from the outset, the other licensees would know the procedures for proper dispensing and labeling that Applicant spent over two years creating and refining. Revealing Applicant’s procedures would also harm Applicant’s competitive position in future bids by impairing Applicant’s ability to distinguish itself competitively in future applications that request this information. R.C. § 1333.61(D)
D-6.8 Inventory Management Process
n/a This question asks applicants to describe their approach to the implementation of an inventory management process. Inventory management processes are necessary to demonstrate an applicant’s ability to operate a dispensary in compliance with regulations. Applicant’s answer reveals a detailed inventory management process created and refined over years of operating in multiple highly regulated markets. Applicant’s method for detailing this process in a bid for a license was developed and refined over a period of years by subject matter experts hired by Applicant. If Applicant’s answer is revealed, competitors will get an unfair peek into Applicant’s proprietary process at little or no cost. R.C. § 1333.61(D)
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D-6.9 Return of Medical Marijuana
D-6.9.1 This question asks applicants to describe their process, procedures and controls regarding a patient or caregiver’s ability to return unused medical marijuana for the purpose of dispossession and destruction. Applicant’s answer is a detailed proprietary plan for dispossessing and destroying unused marijuana derived and refined from operational experience in highly regulated markets. If revealed, Applicant’s competitive advantage in future applications will be harmed as competitors would be able to duplicate Applicant’s plan without the years and expense Applicant spent crafting and refining its proprietary plan. R.C. § 1333.61(D)
D-7.1-Diversion Prevention
n/a The contains a detailed summary of the procedures and controls that Applicant will implement at the dispensary to prevent diversion of medical marijuana, and Applicant’s process that it follows when/if evidence of diversion is identified. Applicant’s answer is a plan for diversion prevention that Applicant developed and continually refined based on its experience operating dispensaries in other states. In addition, Applicant has a team of subject matter experts that are hired at great expense to articulate an answer that goes beyond compliance with applicable Ohio regulations, in order to score the maximum number of points. Revealing Applicant’s answer would harm it competitively in future applications that request this information. R.C. § 1333.61(D)
D-8.1 Sanitation + Safety n/a Applicant’s answer to this question is a narrative description of Applicant’s planned sanitation and safety measures. Applicant’s answer is a proprietary, comprehensive plan based on the knowledge of hired subject matter experts and years of operating in other highly regulated states. Applicant’s plan is very strategic in nature and revealing Applicant’s answer would harm it
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competitively in future applications that request this information, as it could be duplicated by a competitor with little to no effort or expense. R.C. § 1333.61(D)
D-9.2 Recordkeeping n/a Applicant’s answer to this question sets forth a detailed description of its proprietary recordkeeping plan based, in part, on experience operating compliant dispensaries in similarly regulated states and input from experts hired by Applicant. This proprietary plan has formed part of the “special sauce” that has made Applicant successful in multiple bids for licenses in competitive states. Due to Applicant’s success in prior bids and continued competition for state licenses, Applicant’s plan is highly valuable to competitors who wish to copy Applicant’s plan to score more points in bids for future licenses. R.C. § 1333.61(D)
D-10.1 Other Services or Products
n/a This optional question affords applicants broad discretion to choose the other services or products that the applicant will provide, if any. Applicant’s answer is highly strategic and based on successful operations and bids for licenses in other states. Applicant’s plan to provide for other services or products at its facility features certain services or products that were not required by the application. Release of this information would cause significant harm to Applicant’s competitive position in future applications, as it would allow competitors to duplicate Applicant’s “special sauce” ingredients for a successful application at no cost. Further, if awarded a dispensary license, competitors would be able to copy the additional services and products offered thereby eliminating Applicant’s competitive advantage in the state. R.C. § 1333.61(D)
D-10.2 Summary of Intended Services for Veterans + Indigent
n/a This optional question affords applicants broad discretion to choose and highlight their plans for services applicants intend to
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provide for veterans and the indigent. Applicant has a strategy of featuring community services that were not required by the application. In order to score more points on future applications, competitors want access to Applicant’s strategy or “special sauce” that has proved successful in a number of competitive bids for licenses. If revealed, Applicant’s competitors would be able to duplicate Applicant’s “special sauce” causing substantial competitive harm to Applicant. R.C. § 1333.61(D)
D-10.3 Minimization of Environmental Impact
D-10.3.1 This optional question affords applicants broad discretion in deciding what actions to take to minimize their environmental impact. Information that is not required on an application presents a unique opportunity to for applicants to increase their overall score in bids for licenses. Applicant’s plan for minimizing its environmental impact is based on successful operations in other states and its strategy to highlight certain team strengths. If this information is revealed, Applicant’s competitors would be able to unfairly adjust their application or alter their application strategies in an attempt to outscore Applicant in future competitions for licenses. R.C. § 1333.61(D)
E-1.1 Employee Training E-1.1.1 Applicant’s answer to this question is a highly strategic plan based, in part, on successful operations in other states. Applicant crafted and refined a proprietary approach to employee training and education that has allowed Applicant to receive licenses in other highly regulated states. If awarded an Ohio dispensary licenses, competitors in Ohio would have access to Applicant’s employee training plan thereby eliminating any competitive advantage Applicant has from years of refining its proprietary employee training plan based on experience and expert consultation. Applicant will be harmed
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competitively in bids for licenses in the future, if Applicant’s answer is available for copy by competitors. R.C. § 1333.61(D)
E-1.2 Identification + Implementation of Research
n/a Applicant’s answer to this question is a strategic plan for identifying and implementing research that is based, in part, on its successful operations in other states and input of paid expert consultants. Applicant provides a detailed method for identifying and incorporating medical marijuana research that is a competitive advantage in both current operations and future bids for licenses. Applicant’s plan, if revealed, would cause competitive harm in Ohio as Applicant’s competition would be able to duplicate its proprietary research methods without the expense of paid experts or years spent refining from experience. Revealing Applicant’s answer would also cause competitive harm in future applications that request this information. R.C. § 1333.61(D)
E-2.1 Employee Training on Patient Education
E-2.1.1 This question asks applicants to describe how dispensary employees will be trained to provide patient education. Applicant’s answer to this question is a detailed plan Applicant uses for training its employees and is based, in part, on knowledge gleaned from its subject matter experts and experience operating in other medical states. The plan Applicant has developed for training employees on patient education, if revealed, would allow competitors to simply duplicate Applicant’s answer on future application bids. Applicant’s refined plan, if not protected, would be easily duplicated by competitors causing harm to Applicant’s ability to distinguish itself from less experienced competition. R.C. § 1333.61(D)
E-2.2 Adverse Events n/a This question affords applicants broad discretion in describing the processes, procedures and controls for addressing reports of adverse events. Applicant’s plan is
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based on the input of Applicant’s paid subject matter experts and has been refined based on experiences operating in other highly regulated markets. Revealing this information would harm Applicant competitively in future applications that request this information. R.C. § 1333.61(D)
E-3.1-Description of Patient Care Facility
E-3.1.1 Applicant has spent considerable dollars employing architects to develop facility plans that Applicant has refined based on its experiences operating in similarly regulated markets. Applicant’s site and facility plans have allowed Applicant to secure licenses to operate in heavily regulated markets. If Applicant is selected for a dispensary license, the other licensees would know from the outset how Applicant plans to structure its facility and would be able to copy these plans, thereby harming Applicant’s competitive advantage in the Ohio market. Revealing Applicant’s answer would also harm Applicant in other states as competitors would be able to unfairly utilize Applicant’s plan for their stores or application bids. Applicant is a private company that keeps its facility plans strictly private and access is given only to those officers who require access for the purpose of applications and actual operation. R.C. § 1333.61(D)
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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