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    Schedule A forms from application for Arkansas Medical Cultivation and Dispensary permit applications.

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    00041 - 00060_Redacted

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    Schedule A forms from application for Arkansas Medical Cultivation and Dispensary permit applications.

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    © All Rights Reserved
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    Markieren Sie unangemessene Inhalte
    124 Ansichten40 Seiten

    Redacted

    Hochgeladen von

    Russ Racop
    Schedule A forms from application for Arkansas Medical Cultivation and Dispensary permit applications.

    Copyright:

    © All Rights Reserved
    Als PDF herunterladen oder online auf Scribd lesen
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    0004 | APPLICATION FOR MEDICAL MARMUANA DISFENSARY SECTION A. GENERAL INFORMATION 1. Name of Applicant (Must be a natural person.) Ashaansas Wellness Gi ° 2. Business Name Fletitious Trade Name {il'any) 5 Fayetteville, AR 72701 Business ML 4179-395-1917 ness telephone number. ness entity type _Linited Liab ir it 1124 Date of business formation or ineorporation 2/2017 State(s) of Incorporation Arkansas Nirmal & Kilambi Registered Agent Name 1904 Ni + Fayetteville, AR 72701 Registered Agent Address 4. List all owners, stockholders, sieareholders, members, officers, and board members of the proposed dispensary. Identify the nature of the individual's or corporation's affiliation with the proposed di age of ownership, iFany, NOTE: Please make sure 100% of the ownership interest in the preposed dispensary is accounted for in this section (Atiach any necessary additional pages te this ton. Include a header ou any attachments. The besuler tor this response should inelude “Section A. Nuriber 4”) pensary and pere 5. County of Proposed! Location _Washington 6. City of Proposed Location (ifinside city limits)_Fayetteville felts Maeda Sepa nae cot OOOH | 7, Has the applicant oF business entity fled, or does the applicant or Dusiness entity intend 10 ie an additional appMeation for a dispensary license under the samo or a different numie at a different location? If se, please provide the location(s) and any other wame under which the applicatian(s) will be made. owner, stockholder, shareholier, officer, or board member in any way afi any other applicants(s) for dispensarieseultivation centers? If yes, please identify the individual and the name of the prupesed cultivation facility o Siened this 2 2 ay or Ae Sighemure OPA ppheant 23st yor August 207, iba NS La. A Fae ante = - si Sard Me My Commission Hopine: DSawuary |, 2023 © Oran Pua | “2'2P\ 3\ Wastagion County, Arkansas Sia] Seomisin # 12891081 Subscribed and sworn to before me xg)“ eabwsen Bae ee ay 1 2088 dispensary license under the same or a different name at 4 different location? If so, please provide the location(s) and any other name under which the application(s) will be made. NIA Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way aMMliated with any other applicants(s) for dispensaries/cultivation centers? If yes, please identify the individual and the dispens NA ify that the information provided in this form and iisatiachinents compretearosceuate, Tuoerstand that any sissiatement or concealment of fact may be grounds for refusal of application or revocation of license if later disclosed. e ‘Signature of Applicant” ow Sixt and wernt bare mes My Cammission Expires: APPLICATION FOR MEDICAL MAREIUAN \ DISPESSARY EX SHOTION AL LAL INFORMATION 1 Name of apy it st he tngtural person) ‘new Namie Novtlwect Avkansas Medical Dispens ' visines Mitng adres a is Trade Name 6 ang, MM factories AR. Jet03 Mininess telephone nnmber 444-236-2000 roninessentin nee Ayausas Limided Leability Com pars Date of husiness formation wr incorporation, €[2z(r0y 3 stacey ot tnvorporation Pork ans a6 leesiverot \evut Same Semauel Sle Phergon Registered tgent dros \UUZL Goshen Tattle 24. Elemis, AR 92927 dt all owners, stockhaltors. abareholders, members, atfieers, an heearal men D rapes dispensary. Leontify the natin of the inilividisl's a corperition’s ali hotven the propused dispensary and perceatage of oanership, ifany, NDLF: Moos #9 sire dhl HM of the aes nteeship inte SLin the propased dispensany i Betutl Ogenchans 4 Commune Location Waghy agion 6. Cityof Propmedd Location (Ifmoale city tim Fayette ae 2 * n We 401 rth Mea Ya\1010 [ APPLICATION FOR MEDICAL MARIJUANA DISPENSARY TON Name of Applicant (Must be a natura! person.) i Business Name “The Natural Healing Center LLC Fictitious Trade Name (if any) The Natural Heali Business Mailing Address Business telephone number 50) Business entity type Medieal Marijuana Dispensary Date of business formation or incorporation 8-21-2017 Stite(s) of Incorporation: Arkansas Registered Agent Nam John Sir Miclieel Martinez Registered Agent Address 2100 Arkansas Ave. Conway AR. 72034 602 Oak Sure: ! List all owners, stockholders, sharcholders, members, officers, and hoard members af the proposed dispensary. Identify the nature of the in corporation’s affiliation with the proposed dispensary and percentage of ownership, ifany. NOTE: Please make sure that 100% of the ownership interest in the proposed dispensary ix accounted for in this seetion. (Attach at additional pages to this form. Include a header on any attachments, ‘The header for this response should include “Section A, Number 4.”) Jwner — 51% Owner — 49% County of Proposed Location Pulaski County idual’s or necessary City of Proposed La tion (If inside city limits) Not in eity linits (1) CONFIDENTIAL Coo4! pplicant or business entity filed, or docs the applicant or business entity intend to file an additional application for a dispensary Ii different name at a different location? If so, please pros other name under which the application(s) will be made. Notat this ti ‘ase under the same or a Je the location(s) and any 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicants{s) for dixpensaries/euttivation centers? If yes, please identify the individual and the name of the proposed cultivation facility or dispensary, and briefly describe the nature of the relationship, No ification I. certily that the information provided in this ore fate. [understand that any misstatement oF concealment of fact may be grounds for refusal of application or revocation of license if late disclosed Signed this___{ ‘ore me this_7/\ day of Subscribed and sworn to Bian att f ¢ Chat Notary Public My Commission Expires: /) [oy {9 (UCONFIDENTIA as Medieel Marjan Dispensan, License Applica 26 Compas igate Cae Conipany Seston A On0d S APPLICATION FOR MEDICAL MARNJUANA DISPENSARY ae SECTION A. GENERAL INFORMATION 1. Name of Applicant (Must be a natural person.) Mim 2. Husiness Name Arkansas Compassionate Care Company Group, LLC Fictitious Trade Name (if'a ) ing Ad A sei, A 72900 Business Ma Business telephone number (475) 870-6614 3 Busi ess entity type Lentec Lizbitty Corporation Date of business formation or incorporation 9012017 State(s) of Incorporation Arkenses Registered Agent Name Yanai Walker Register 804 S, Commerce Ave Russetlalle, AR 72801 Agent Address 4. Listall owners, stockholders, shareholders, members, officers, proposed dispensary. tdentify the ividual’s oF eorpor: with the proposed dispensary and percentage of ownership, if any. NOTE: sure that 100% of the ownership interest in the proposed dispensary is aecoun section. (Attaclt any necessary additional pages to this form, Include a het ata on A, Number 4") ure of the ‘iments. ‘The header for this response should inelude 51% re ‘County of Proposed Location Pop 6. City of Proposed Loca n(lt nside cit limits) London Akonss Compassionate Care Compoy, 3p file an additional application for 3 a different location? If so, please provide the laeation( the application(s) will be made. 8. Isthe Applicant or any owner. stockholder. sharchold inlicant or business entity filed. or does the applicant or business entity int 98 weak! argue Lspetseny Leemie appkcten spensary license under the same or a different name at any other name under which No officer. or board member in any way affliated with any other applicants(s) for dispensaries/cultivation centers? If yes. please identify the individual and the name of the prop ed cultivation facility or dispensary. and briefly deseribe the nature of the relationship. ww 28 coor Au a be grounds for refusal of application or revocation of hcense if later disclosed Cerfieamon provided in this form svsansas Nal Prod Maniuena Dispensary Lense Appiaticn! Sesion A APPLICATION FOR MEDICAL MARIJUANA DI SECTION A. GENERAL INFORMAT! 1 Name of Applicant (Must be a natural person.) Arkansas Natural Products 1. LLC 2, Business Name Fietitions Trade Name (if'any)_N/* 0g Ass Russellville, AK 72801 Business M: 479-747-8780 Business telephone number 3. Tusiness entity type _Limted Liability Comporation Date of business formation or incorporation_/31/2017 State(s) of Incorporation Arkansas Registered Agent Name_"2#ehiel Nehus Registered Agent Address _ 200 North Q) {all owners, stockholders, shareholders, members, officer ‘af the individu proposed dispensary. [entily the nan with the proposed dispensary and percentage of ownership, sure (hat 100% of the ownership is section, (Attach any necessury audition pages to this form Include a header on any attachments, The header for this response should inelruke “Scetion A, Number 4.") ferest in the proposed dispensary is accounted for in this Member, 24.5% J Member, 24.5% Member, 31% vk Natur Pods ss Medes Miia Dips Lome Apietin Beat 6 7, Has the applicant or business entity filed, or does the applicant or business entity intend to file an additional application for a dispensary license under the same or a different name at a different location? If so, please provide the location(s) and any other name under which te application(s) will be made. 8, Is the Applicant or any owner, stockholder, shareholder, officer. or board member in any way affiliated with any other applicants(s) for dispensaries/cultivation centers? If yes, please identify the individual and the name of the proposed cultivation facility or dispensary, and briefly describe the nature of the relationship, Yes, Natural persons intend to tlie appl ‘Arkansas Natural Products TT is also an advisory board member for Arkansas Company Group sation __ certify that the information provided in this form and its attachments is complete and accurate, I understand that any misstatement or concealment of fact may be grounds for refusal of application or revocation of ticense if later disclosed. Signed this 22% —diyot__fagaatt ee eo Ate are ppucant Subscribed and sworn to before me this _ day of Augus Qt Bee eM Publi My Commission Expires: 37-2027 RENEE WILEY NOTARY PUBLIC “ARKANSAS POPE COUNTY My Commision pres 04132027 ‘Comission No, 12700698 COO4 4) APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. 1, Name of Applicant ‘te person.) . posines Name Neate! sei Healthcare, (nc. Fictitious Trade Name (if any Business Malling Address Vom Byren T2456 Business telephone number 1$-9S1- 711714 NERAL INFORMATION 3s. Business eniry type Corpovadti ou : Date of business formation oF incorporation, ovembtr 26, 2016 State(s) of Incorporation Aransas sgt Corey Hunt ret Ageut tires WTF Reh Bolan Dr, Von Buren / T2ASY |. List all owners, stockholders, shareholders, members, officers, and board members of the at 100% of the ow ction. (Atta sary additional pages to this form. Inclukle & h attachinents, The riage should include “Section A. Number 4.") _ See attached een 5. County ofPropod Location COW Fork 6. City of Proposed Location (If inside city limits COON? 7. Has the applicant or business entity filed, or does the applicant or business entity intend to file an additional application for a dispensary license under the same or a different nome at 1 different location? If so, please provide the location(s) and sny other name under which the application(s) will be made. 8. Is the Applicant or any owne way affiliated with any other applicants(s) for please identify the individu dispensary, and briefly describe the Wo. 2 yes, ion may be grounds for refusal of application or revocation of license if tater disclosed 9 tn 213 prature of Applicant Subscribal and sworn bofore nb this 7 day of SEO KENNEL 2uN1 ONC By Fort boy a Notary Puiblig My Commission tspirss ULAR 27] ‘OFFICIAL SEAL KELLEY LOAEZA NOTARY PUBLIC. ARKANSAS YELL. COUNTY Commission rr2701420 COMMISSION EXP. colesater COO“ S APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A, GENERAL INFORMATION 1. Name of Applicant (Must be a nctura persen,) MMC PPP, LLC 2, Business Name Fictitious Trade Name (ifany) Ozark Healing Center Business Mailing Address, Fayetteville, Arkansas 72704 479-387-5603 5 telephone number _ 3. Business entity type Limited Liability Company _ Date af business formation wr incosporation_ 0 State(s) of fncorperation Arka Regictored Agent Name 4. List all owners stwekholdcrs slurcholders, members, officers, and board members ofthe proposed dispensary. Identify the mature ofthe individuat's or corporation withthe proposed dicpensary and percentage of ownership, if any. NOTE: Pease sure that 100% af the awnership interest in the proposed dispensary i accounted For in this section. (Attach any necessary akiional pages to this form, clude a header on any acachrents. Ths head for this response shoul ued “Seevion A, Number 4") The applying entity Is MMC PPP, LLC. The owner hip ofthe applying ently Mom herp ltrs MCR ILC Fang SDP Invstess “mcuc Fi Chae Pooper LEC Ny Heldgs, LLC = County of Propased Location __ Washington Count 6. City of Proposed Location (inside cy limits)_Fayetteville, Arkansas OOK & 1, Has the applicant or business entity filed, or dues the applicant or business entity intend to file an additional application for a dispensary license under the same or a different name at a different location? Ifso, please provide the location(s) and any ather name under which the application(s) will be made No 8. Te the Applicant o any over, stockholder, shareholder, officer, or board member in any ‘way affiliated with any atber applicants(s) for dispensariesicultivation enters? Htyes, please identify the individual and the name aft ispensary, and briefly describe the nature af the relationship ropased cultivation facility or No certify Mat the Bafummsation provided in this form Fee ee eee darn that any misstatement a eo nto Tet signa tis 30° aayor 2<7_A vu , AA? Siguathre of Apprtesar Subribed and swou to store wie this CO ay of (hilo ast aor Bn bee ken ner ‘Notary Public My Commission Expires: | UES hoy SESLIE KENNEY” NOTARY PUBLIC-STATE OF ARKANSAS | MHRSHINGTCN COUNTY ly Commission Expires 06:28.2007 ‘Comm 00050 APPLICATION FOR MEDICAL MARIJUANA DISPENSARY ‘SECTION A, GENERALINFORMATION 1, Name of Applicane (Must be a natural person.) ns s—C‘CS 2, Business Name Absolute Essenc: Fictitious Trade Name (if any), Business Mailing Address SIN. Bryant, Arkansas 72022 Business telephone number 501-548-5857 3. Business entity type LLC. Date of business formation or ineorporation_July 10,2017 State(s) of Incorporation Arkansas, Registered Agent Name Timothy Bryce Hendrix Registered Agent Address 10605 Paul Bells Dr #2 North Little Rock, AR 72113, 4. List all owners, stockholders, shareholders, members, officers, and board members of the proposed dispensary. Identify the nature of the individual's or corporation's affiliation ‘with the proposed dispensary and percentage of ownership, if any. NOTE: Please make sure that 100% of the ownership interest in the proposed dispensary is accounted for in section. (Attach any necessary additional pages to this form. Include a header on any attachments. The header for this response should include “Section A. Number 4.") MER 027, CEC 3 shareholder MERE..0 nc. operat, 3°3.% sharcholder M0» 33% starcholder 5, County of Proposed Location Saline 6. City of Proposed Location (if inside city limits)_Bryant Has the applicant or business entity filed, or does the applicant or business entity intend 10 fle an additional application for a dispensary license under the same or a different name at a different location? If so, please provide the location(s) and any other name under which the application(s) will be made. No 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any jated with any other applicants(s) for dispensaries/eult identify che individual and the name of the proposed cultivation fucitity or ation centers? If yes, No Conification 1, PT certify that the information provided in this form and iavachmentsts complete ndlaccurste. Tundérstand tht any misstatement or conceaient of fact tay be grounds fr resal of application at revocation of license if ater disclosed. signed this © 74 aayor__? gt eid Subscribed and sworn to before me this My Commission Expires: POWELL Putas Cour APPLICATION FOR M DOO Ss) ICAL MARIJUANA CULTIVATION FACILITY SECTION A. GENERAL INFORMATION Name of Applicant (Must be a natural person.) Business Name _Big Oak Pharms LLC Fictitious Trade Name (if any) Business Mailing Address Clarksville, AR 72830 Limited Liability Company Bus type Date of business formation or incorporation_98/01/2017 te(s) of Incorporation _ Arkansas United States Corporation Agents, Ine Registered Agent Name 260 Shoppingway Blvd Ste A & B. West Memphis, AR 72301 Registered Agent Address Bh V 1 3S LL DOOF! 4. List all owners, stockholders, shareholders, members, officers, and board members of the proposed cultivation facility. Identify the nature of the individual's or corporation's affiliation with the proposed cultivation facility and the percentage of ownership, ifany, NOTE: Please make sure that 100% of the ownership interest in the proposed cultivation facili accounted for in this seetion. (Attach any necessary additional pages to this form. Include a header on any attachments. The header for this response should include “Section A. Number 4.") SR. Member 60% Equity HE Member, President 40% Equity Johnson 5. County of Proposed Location 6. City of Proposed Location (If inside city limits) 7. Has the applicant or bu: entity filed, or does the applicant or business entity intend to file an additional application for a cultivation facility license, under the same or a different name at a different location? If so, please provide the location(s) and any other name under which the application(s) will be made. The applicant has not and does not intend to file any additional applileation Tor a cultivation license 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) for (002) dispensaries/cultivation centers? If yes, please identify the individual and the name of the proposed cultivation facility or dispensary, and briefly describe the nature of the relationship. Centitican ion hh , certify that the information provided in this ‘A mnd accurate, | understand that any misstatement or conceaiment of fact may he grounds for refusal of application or revocation of license if later disclosed, signed this O3 ay op ot 2017. Signature of Applicant 3 Pd and swor to before me this DS dayor Ququst. T” Notary Public My Commission Expires: [D “Ol - BOA 00052 APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY SECTIO! Lu ATION 1, Name of Applicant (Must be a natural person.) OU eee 2, Business Name _ Applegate Valley Organics of Arkansas, LLC Fictitious Trade Name (if any)_NV/A Business Mailing Address SI 7 — Portland. Oregon 97232 Business (elephone number _ (971) 703-4777 3. Business entity type _ Limited Liability Company Date of business formation or incorporation August |1, 2017 State(s) of Incorporation ___Ackansas Registered Agent Name ___ Corporation Service Company Registered Agent Address 300 Spring Building, Suite 900 300 S. Spring Street Little Rock, AR 72201 C0 SL 4. List all owners, stockholders, shareholders, members, officers, and boar members of the proposed cultivation facility. Identify the nature of the individual's or corporation’s affiliation with the proposed cultivation facility and the percentage of ownership, if any. NOTE: Please make sure that 100% of the ownership interest in the proposed cultivation facility is accounted for in this section. (Attach any necessary additional pages to this form. Include a header on any attachments. The header for this response should include “Section A. Number 4.”) MR | 60° ner of Applegate Valley Organics of Arkansas, LLC of Arkansas, LLC MR | 37.4% owner and CEO of Applegate Valley Organi = 2% owner and COO of Applegate Valley Organics of Arkansas, LLC = 6% owner and CFO of Ay legate Valley Organics of Arkansas, LLC County of Proposed Location Monroe - EEE Holly Grove. AR 6. City of Proposed Location (If inside city limits}|_utside city limits 7. Has the applicant or business entity filed, or does the applicant or business entity intend to file an additional application for a cultivation facility license, under the same or 9 different name at a different location? If so, please provide the location(s) and any other name under White County Mississippi County 8, Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) for ae L0S2 idual and ity or dispensary, and briefly dispensaries/cultivation centers? If yes, please identify the indi the name of the proposed cultivation f describe the nature of the relationship. All owners of Applegate Valley Organics of Arkansas, LLC are also owners of Nectur Markets of Arkansas, LLC. Each entity is submitting multiple applications for cultivation and dispensary licenses, respectively fy that the information provided in this ny misstatement oF jusal of application or revocation of license if late fiselased sienea tis |S aay or_ Soptomboer 2014 bed and swarn ta before me this es day of gS Y [xc Zot Ie. =. \ Qnnctita O Se v a Por My Commission Expires: J/ 2 6 -D(p OOD D> APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION NI XFORMATION Name of Applicant (Must be a natural person.) FO 2. Business Name River Valley Sales, LLC Fictitious Trade Name (ifany)_River Valley Relief Dispensary Address Fort Smith, AR 72916 Businoss Mail Business telephane number _ 479-649-6908 s entity type_Limited Liabi 3. Busi Company Date of business formation or incorporation_July 25th, 2017, mn Arkansas Registered Agent Name _ John D Alford Ristered Agent Address 6804 Rogers Avenue, Suite B, Fort Smith, AR 72903 _ State(s) of Incorpora 4. List all owners, stockholders, shareholders, members, officers, and board members of the propased dispensary, Identify the nature of the individual's or corporation's a with the proposed dispensary and percentage of ownership, if any. NOTE: Please make sure that 100% of the ownership interest in the proposed dispensary is accounted for in this, section. (Attach any necessary additional pages to this form. Include a header on any attachments, The heatler for this response should include “Section A. Number 4.”) EE « Member - 50% Ownership $. County of Proposed Location Sebastian 6. City of Proposed Location (If inside city limits)_Fort Smith ©0054 7. Has the applicant or business entity filed, or does the applicant or business entity intend to file an additional application fora dispensary license under the same or a different name at a different location? If so, please provide the location(s) and any other name under which the application(s) will be made. No. fed with any other applicants(s) for dispensaries/cultivation centers? Ifyes, individual and the name of the proposed cultivation fx dispensary, and briefly describe the nature of the relations Yes the 100% owner of River Valley Production, LLC DBA River Valley Relief Cultivation. and are also officers of River Valley Production, LLC. River Valley Production, LLC is submitting two applications for a cultivation facility license. 7s ceatifythat the information provided in this form nd accurate. | understand that any misstatement or concealment of fact iy be grounds for refusal of application or revocation of license if later disclosed Signed this 14th __day of gSeptember Subscribed and sworn to before me this ||“ day of _

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