Qo|Z 2 APPLICATION FOR MEDICAL MARIJUANA CUI LTIVATION FACILITY TION 1, Name of Applicant (Must be a natural person.) 2. Business Nam MEDICAL GROUP, LLC ous Trade Name (if any) N) 3. Business entity type__ LLC. 5 ati tee won 47-47-17 Date of business formation or incorporation__“1 U7 State(s) of Incorporation Aw le anSccs Registered Agent Name rahe Carpenter. Registered Agent Address (Qi4 Carpenter Road, Grady, Avkansas Wh4469 (TO 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, 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.) (I (04% owner) 2 i [1% Owner) 3 Webb % o t 4. Vlele Yo owner 5 Ub %e @ 5. County of Proposed Location, ol 4 6. City of Proposed Location (If inside city limits) 4 al Grad 7. Mas 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 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 will not be Kling an addidinn a Opolicdh on fae a culhvahon Pacibhy license. 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any Way affiliated with any other applicant(s) for0O\ 20 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. See attaned. , “Section A Nu vier %” Certification L on oe , cestify that the information provided in this form and its attachments is complete and accurate. I understand that any misstatement or concealment af fact may be grounds for refusal of application or revocation of license if later disclosed. qin Signed this day of _ Seghembec tay, Subscribed and sworn to before me this day of “SE OTEWV Viger, Zo = Notary Public My Commission Expires DANA MEYER. Notary Pubic State of Colorada Notary 19 20354000023 Commission Expires Mar 10,2019,; ae OO\2-\ APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A, GENERAL INFORMATION 1, Name of Applicant (Must be « natural person.) ie * A* 2 Business Name Na\entine Wilding LLC, ictitious Trade Name (if Business Mailing Address. Saoresboro A W403, Business telephone number 3. Business entity type Lygated Ladlality ampany, _4 incorporat Age \ Wo, 201! State(s) of Incorporation Ax Kansas Registered Agent Name Qopa\a L. Pas Ker IE Registered Agent Address S00) BrowaS Lane, Sonesboro AK N40) Date of business formation 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 this section. (Attach any necessary additional pages to this form. Include a header on au attachments. The header for this response should include “Section A. Number 4.") 1.3334 Mo .3333%% =\%4o 33.3353 5. County of Proposed Location Washinetna Coyshy 6. City of Proposed Location (Ifinside city limits) FauetyileOO\2\ 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? Iso, please provide the location(s) and ary other name under which ss ill 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/eultivation centers? If yes, please identify the individual and the name of the proposed cultivation faci d briefly describe the nature of the relationship. Conification . certify that the information provided in this form urate, Tunderstand that any misstatement or concealment of fact may be grounds for refusal of application ot revocation of license if ater disclosed signed tis JA day or_Se ber . A0i7 Subscribed and sworn o before me this [® day or September 20.7) aad Yel Notary Public My Commission Expires: \\- WoTAee PL SATE OF ARKANSAS PANGOLPH COUNTY Wy commtsn ee 208OQ1\ae APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY SECTIO® a RAL INFORMATION 1, Name of Applicant (Must be a natural person.) 2. Business Name New Harvest Agri, LLC Fictitious Trade Name (if any) N/A Business Mailing Aceves Marianna, Arkansas T2360 Business telephone number N/A . Business entity type Limited Liability Company Date of business formation or incorporation December 16", 2016 State(s) of Incorporation Arkansas Registered Agent Name Michael Osburn Registered Agent Address 2800 Highway 1 South Marianna, Arkansas 22360DO*'\2e dispensaries/cultivation centers? If yes, please identify the individual and the name of the proposcd cultivation facility or dispensary, and briefly describe the nature of the relationship. see all equity holdors ina dispensary applicant LL. named New Harvest ification i concealment! of fact miay be grounds far seCusal oF apolication or revocation of license iT later disclosed seetns 2 wwe SENTEUS EGE DAT and swom ty before me this ose Cusco Natary Public ee is FRAN My Commiss nn pu ab por ALES GF HHSHS sion Expves san 26, 2020 | Ny Commision Be sasranee sy we 51SECTION A. PAGE 001 CO\2ZS APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY TION A. GENERAL INFORMATION 1. Name of Applicant (Must be a natural person.) 2. i: . Business Name Fictitious Trade Name (if any)_N/A Business Mailing Address_ (EE Jonesboro, AR 72401 Business telephone number _ (501) 235-8336. Business entity type imited iy Company Date of business formation or incorporation July State(s) of Incorporation _Agkansas Registered Agent Name __ Bart Calhou Registered Agent Address 1020 West 4th Street, Little Rock. AR 72201SECTION A. PAGE 002 OO\}2-3 members, officers, and board ity. Identify the nature of the tion with the proposed cultivation facility and the percentage of ownership, if any. NOTE: Please make sure 4. List all owners, stockholders, shareholders members of the proposed cultivation fa individu I's or corporation's: afi 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 @ header on any attachments. The header for this response should include “Section A. Number 4.") Owner LOI%. Owner 1.56% Owner 7.7% Owner 156% ess) | Owner 2.08% Owner 5.19% BBB. wner 2.08% BR 0 ver 1.03: Owner 1.56% Owner 3,00 == Owner 1.04% Owner 3,004 GH or. 0vner Loe Quner 2.00% GE snc 1.04% . 31% nner 2.08% Owner 0.51% = Owner 2.60% Ouner 0.18% SE s.r 1.01% 8. County of Proposed Location__Jefferson 6. City of Proposed Location (I! inside city limit mits of Pine Blufl: AR 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 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. Yes.) sN Wellness Entemriss 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) forSECTION A. PAGE 003 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. LL L tity that the information provided in this, form and ts attachments is complete and accurate. 1 understand that any misstatement or concealment of fact may be grounds for refusal of application oF revocation of Hicense if later disclosed Signed this__ day of “entifi Signa page attached) are of Applicant ed and sworn to before me this Notary Public My Commission Expites:SECTION A. PAGE 001 OO\ZY APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY SECTION GENERAL INFORMATIO! 1. Name of Applicant (Must be a natural person.) mT 2. Business Name _ Natural State Wellness Enterprises, LLC tious Trade Name (if any) N/A 2 Address. | Jonesboro, AR 72401 Business Mail Business telephone number _ (501) 235-8336 3. Business entity type _ Limited Liability Company Date of business formation or incorporation_Jul States) of Incorporation __Arkansas Registered Agent Name __ Bari Calhoun Registered Agent Address _ 1020 West 4th Street, Little Rock, AR 72201SECTION A. PAGE 002 C0124 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, 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.”) i a mA Owner L04% Diner 34.00% Owner 1.56% Dwner 7.79% Owner 1.56% er 3.12% Owner 156% Owner 1.04% 2.0 wer 1.56% | Owner 5.19% Owner 2.08% Owner 1.04%. SR Owner 1.56% BE. ner 3.00% Owner 1.04% wner 3.00% wn % Ow Owner 1.04% | Owner 0.31% Owner 2.08% Owner 0.51%. Owner 2.60% Owner 0.18% | Owner 01% 5. County of Proposed Location _Jc et 6. City of Proposed Location (If inside city limits) Outside city limits of Pine Bluff. AR 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 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. Ves. Jackson County as Natural State Wellness Enterprises. LLC 8, Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) forSECTION A PAGE 003 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. —(Please see the attached document for answers to #8) __ I certify that the information provided in this allachments is complete and accurate, | understand that any misstatement or concealment of fact may be grounds for refusal of application or revocation of license iC later disclosed. Signed this day of. (Certification page attached = of Applicant ‘Subscribed and sworn to before me this day of . Notary Publ My Commission Expires:SECTION A PAGE 004 CULTIVATION APPLICATION SECTION A. GENERAL INFORMATION, #8 #8, Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) for dispensaries/cultivation centers? IF yes, please identify the individual and the name of the proposed facility or dispensary, and briefly describe the nature of the relationship? ‘The following individuals are affiliated with Natural State Wellness Enterprises, LLC (submitting two cultivation applications with locations proposed in Jefferson County and Jackson County) and Natural State Wellness Dispensary, LLC (submitting six dispensary applications with locations proposed in Little Rock, Jonesboro, Fort Smith, and Pine Blut) 1 ~ Named Applicant and Owner 2 - Owner 3. = Owner 4 ~ Owner (note: only an owner of Natural State Wellness Dispensary, LLC) s - Owner 6 - Owner 1 - Owner 8. Owner 9 ‘Owner 10] — Owner/ Manager itt Owner The following individuals are affiliated with Natural State Wellness Enterprises, LLC and both cultivation applications for that company with proposed locations in Jefferson County and Jackson County 1. RIS — Named Applicant ‘and Owner 2 - Owner 3 Owner 4, | Owner 5 - Owner 6. Owner Neuropsychologist | Owner/ManagerSECTION A. PAGE 005 Certification {, INN :1i'y that the information provided in this form (Section A) and its atlachments is complete and accurate. | understand that any misstatement or concealment of fact may be grounds for refusal of application or revocation of license if later disclosed. Signed this, /S” __ day of September, 2017 Sms Subscribed and swam to before me this _|723" day of September, 2017 ferhone tbl a Notary Publie : O2-M-2027 My Commission ExpisSECTION A, PAGE 001 00 (22 APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. GENERAL INFORMATION 1. Name of Applicant (Must be a natural person.) 2. Business Name _ Natural State Wellness Dispensary, LLC Fictitious Trade Name (if aay) Business Mailing Address in my 3. Business entit Date of busi ss formation or incorporation_Septemt Statu(s) of Incorporation Arkansas oo Bb Cabo Registered Agent Address. Registered Agent Ni 4. List all owners, stockholders, sharcholders, members, officers, and hoard members of the proposed dispeasary. [entity the nature of the individual's oF corporation's affiliation with the proposed dispensary and percentage of ownership, ifany. NOTE: Please make c that 100% of the ownership interest in the proposed dispensary is aceounted for in this section, (Attach any necessary additional pages to this form, Inclixle 9 heaker on any The header for this response should inelide “Section A. Nunber 4,") icant Oss 51009 M0 crs ns 6.00% , —— jr Owner 6.000, ees [rr IS 0500 6.00". PE =O 6,00" Meco ss 5, County of Proposed Location Jeff Counts 6. City of Proposed Location (Itinside city Hmits)__B. Bluil, ARSECTION A. PAGE 002 00(25 7. Has the applicant or business entity filed, or does the applicant or business ent file an additional application for a dispensary license under the same or a different name at a different location? [fso, please provide the location(s) and any other name under which the application(s) will be made, Yes, as Natural State Wellness ¢ appli submit four applications with locations propased in Jonesboro, Fort Smith. Little Rock. and Pine Biufl 8. Isthe Api fy the individual and the name of the proposed cultiv’ dispensary, and briefly describe the nature of the relationship. —tSeetheanached page with answers in Section A. #8) Certificate 1 certify that the information provided in this form and ils allachments is complete and accurate. Tunderstand that any misstatement or concealment of fact ‘may be grounds for refusal oF application or revocation of license if later disclosed Signed this day of 5 Subseribed and sworn to before me this y of Notary Public My Commission Expires:SECTION A. PAGE 003 IN \7_= DISPENSARY APPLICATION go) Cae SECTION A. GENERAL INFORMATION, #8 48, Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) for dispensariesicultivation centers? If yes, please identity the individual and the name of the proposed facility or dispensary, and briefly describe the nature of the relationship? The following individuals are affiliated with Natural State Wellness Enterprises, LLC (submitting two cultivation applications with jocations proposed in Jefferson County and Jackson County) and Natural State Wellness Dispensary, LLC (submitting six dispensary applications with locations proposed in Little Rock, Jonesboro, Fort Smith, and Pine Blut?) Named Applicant and Owner - Owner - Owner Owner (note: only an owner of Natural State Wellness Dispensary. LLC) - Owner - Owner Owner -Owner ‘Owner Owner! Manager Owner The following individuals are affiliated with Natural State Wellness Enterprises, LLC and both cultivation applications for that company with proposed locations in Jefferson County and Jackson County Owner xd Applicant 45. Owner 17. - Owner 18, 4 - Owner 19. 5 = Owner 2. 6 = Owner 2 Owner 7 Neuropsychologis 2 8 — Owner/Mana 23 Dwner Own: 24. Owner 25 |- Owner ‘Owner 26, 12, Owner 27 Owner OwnerSECTION A. PAGE 004 Ole | EN V, certify chat the information provided in this form (Section A) and iis attachments is complete and accurate. [ understand that any misstatement or concealment of fact may be grounds for refusal of application or revocation of license if later disclosed. Certification Signed this /3 _ dey of September, 2017 Subscribed and swom to before me this _|“23** day of September, 2017. Bs dfs tdbfalo ‘Notary Public My Commission Expires: (72 -}I-2SECTION A. PAGE 001 OO126 ERAL INFORM Name of AppHeant (Must be # natural perso.) ee Bus ss Name __ Natura! Siate Wellness Dispgnsury, LLC Fictitious Trade Ni Business Mailing Address III MI MMM iu te 0 Business telephone number _ (sui 235-8386 Business entity type Linnea Pity Cpu Date of be September L120 State(s) of Ineo:por "Arkansas Registered a Name Bau Culuoun Rowisteved Agent Adress [020 Wh Stave itl Bo zu _ s.stuckholders, sharehiliers, members, proposed dispensary. Iientify the nature of the tn with the proposed dispensary sure that aTteers, and hosted 1's oF corporation's at nit prereentage of wssnership, Hany. NOTE: Please make of the ownership interest ia the propesed dispensary is accounted fur in this seotion, (Attach any necessary additional pases to this farm Incluale shader om ny aiaclaments, Ue bes Seetion A, Nurmbers.") 5 ener 0.49% MN = - 7 Owner 6.004, _ Onset 6,01 _ 6. County of Proposed Lo tion lush County City of Proposed Location (IVinside city limits) Liuhe Rock. ARSECTION A. PAGE 002 OO|26 or does the applicant or business entity + license under the same or a different under 7. Has the applicant or business entity fil file an additional application for a dispe a different location? If 50, please provide the location(s) and any oth the application(s) will be made. ‘Yes, is Natural Stae Wellness Dispensiny LLC The applica SAI suits four applications with logations proposed in Jonesharo, Fort Smith, Little Rock, and Pine Blut 8. ISthe Appl owner, stockholder, shareholder, officer, or board member in any ay ied with any other applicants(s) for dispensaries/cultivation centers? Ifyes. please identify the individual and! the name of the proposed cultivation facility or dispensary, and briefly describe the nature of the relationship. i Isc atiaced page with answers lo Section A. 28) —— ——_ — _*; _. eertif) that the in te and acc and its attachments fs comp nay be grounds for refisal of application of revocation of license i later disclosed jon provided in this form misstatement or concealment af Ect Tonderstand that Signed this __ day of Soe the attached signed Conificution) ‘Signature of Applicant Subscribed aint swont to before me this tay of Notary Publig My Commission EpinesSECTION A. PAGE 003 DISPENSARY APPLICATION OOI\ZG@ SECTION A. GENERAL INFORMATION, #8 L e #8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) for dispensaries‘cultivation centers? IF yes, please identify the individual and the name of the proposed acility or dispensary, and briefly describe the nature of the relationship? The fotlowing individuals are affiliated with Natural State Wellness Enterprises, LLC (submitting son County and Jackson County) and ensary applications with locations 1sv9 cultivation applications with lavetions proposed in Jef Notural State Wellness Dispensary, LLC (submitting six di proposed in Little Rock. Jonesboro, Fort Smith, and Pine Bluf: 1 Named Applicant and Owner 2 ~ Owner 3 ~ Owner 4 Owner (note: only sn owner of Natural State Wellness Dispensary, LLC) 5 - Owner 6 = Owner 1 = Owner 8 Owner 9 Owner 10. Owner! Manager Owne! The following individuals ave affiligted with Natural State Wellness Enterprises, LLC and both cultivation applications for that company with proposed locations in Jefferson County and Jackson County 1, SRI | Narscd Applicant and Owner = Owner 4 ~ Owner |- Owner 5 + Owner Owner 6 - Owner J- Owner Neuropsychotogist Owner/Man: — Owner - Owner | Owner - Owner Owner 2 ‘Owner wner OwnerSECTION A PAGE 004 OO(Z © Certification {2 tt tho information provided in this form (Section A) and chments is complete and accurate. [ understand that any misstatement or concealment of jon or revocation of license iflater disclosed. fact may be grounds for refusal of applics signed tis /3™ day of Septemsber,2017, 2017 day of Septer Subsorbed end swom to before me his_| tp ngfaney (Abfalo Notary Public (/ My Commission Expires: (J2-]- 2027OO\2 APPLICATION FOR MEDICAL MARUIU ANS DISPENSARY ERAL ECTION A. G FORMATION 1 Name of Applicant (. 2. Business Name Natura! Sue Wellness Disnensar LIC Fictitious Trade S Business Maiting Address He Bunch Business telephone number 3, Business entity type bility Cums _ Date of business formation or incorporation Sepiembsr 11, 2U Statets) of Incorporation —Atkass. Registered Agent Name Hur Gufhauy Registered Agent Address [QW tein Sheet Lit AL Listall owners, stackholders, sharehallyrs, menahers, afficers, and board members of the propmved dispensary. HMentify the nature of the individual's or corporation's affiliation ofawnership, ian. NOTES Meuse make sure that 100% uf the ownership interest in the proposed dispensary is acenunted far in this section. (Aigacth and te tainal perges to this Four, Inch 6. City of Proposed Location (IF inside city limits 1 wrSECTION A, PAGE 002 OOI\z) 7. Has the applicant or business entity filed. or does the applicant or business entity intend to file un additional application for a dispensary license uneler the sme ov a different a afferent location Ifso, please provide che locativa(s) aid any oth under whieh, the application(s) will be made. wal Stave Wellness Dispensan, LLC. The applica suluniued Tour applications with lscalioes propused in Jonesboro, Fort Sunith, Lille Reck, aid Pine Blut App WoW ner, stockholder, shareholder, officer, ar board member in amy way alfiliated with any ather applicanis(s) for dispeassriesieultivation centers? Iyes, please identify the individual anc! (he name of the proposed culivatian facitity or dispeusary and briefly deseribe the nature af the relationship. (Se the auwhed page with answers to Seotion A. 2S) Centiiextion es cert) shat the fersvation provided ie duis tare sand Tis afaehnicnis i complete and accurate, T understan Js far vefasal oF application os reve 1 of ices it cf tet lay of =. (Seethy tached signed Centitica — Signattrs oF Applicant Subserihed! and swan ty betore me this sy of Nouary Public My Commission Espines:SECTION A. PAGE 003 7 DISPENSARY APPLICATION OOZLT SECTION A. GENERAL INFORMATION, #8 #8. Is the Applicant or any owner, stockholder, shareholcer, officer, or board member in any way liated with any other applicant(s) for dispensaries/cultivation centers? If yes, please identify the individual and the name of the proposed facility or dispensary, and briefly describe the nature of the relationship? The following individuals are affiliated Natural State Wellness Enterprises, LLC (submit ‘two cultivation applications with locations proposed in Jefferson County and Jackson County) and Natural State Wellness Dispensary, LLC (submitting six dispensary applications with locations proposed in Liitle Rock, Jonesboro, Fort Smith, and Pine Blu): Named Applicaat and Owner Owner 8 Owner 9 ‘Owner 10. Owner/ Man ul Owner ate Wellness Enterprises, LLC and both cultivation applications for that company with proposed locations in Jefferson County and Jackson County 1. RI — Narnca Applicant Owner and Owner | Owner 2 - Owner Owner 3 - Owner 4 - Owner |. Owner 5. - Owner Owner 6 ~ Owner ; [- Owner 7 Neuropsychologis 8 Owner/Manage Owner 9 Owner ‘Owner 10 |- Owner Owner OwnerSECTION A. PAGE 004 Certification 1 I tify nat the information provided in this form (Section A) and @ and accurate. I understand that any misstatement or cancealment of fact may be grounds for refusal of ap ation of license if later disclosed. 13" cay oF Septeciber 2017 Signatu : ican _ day of September, 2017 cation or Subscribed and swom to before me this} 4D idflinvy (bbe Notary Public ()SECTION A. PAGE 001 ae zm OO\Z6 APPLICATION FOR MEDICAL MARMIUANA DISPENSARY SECTION A. GENERAL INFORMATION 1 Name of Applicant (Aust be a natural person.) 2. Business Name Natural State Wetlness Dis Fictitious Trade Name sit Business Mailing Address — SI MMMM us oka 7324 — Business (elephone aumber (3g n 3. Business entity (pe | dpsed Gail Compan Date of husiness formation or incorporation_Sepien mM State(s) of Incorporation _Aykanss Registered Age Na ne Bart Calhoun Registered mi Address uu 4. List all owners, stockholders, shareholders. nembers, officers, and bard members af the proposed dispensary. entity the matt with the proposed disp cof the individuat's or corporation's affiliation sity and percentage of ownership, any, NOTE: Please make sure that 100% of the ownership interest in the propused dispensary is aeemuated far it this section, (Attach uny necessary asklitinnal pages tv this form. Ines a ligtdey on stlachments. “Ulke header Dir this rayparnse should include "Section A. Nur ) SOs. ner 9 Ut svsarccn i SE Osc —— $8. County of Proposed Location __Ce 6, City oF Proposed Location (If inside city liniisy_lenesbore. ARSECTION A. PAGE 002 COILS 7. Has the applicant or business entity filed, o does the applicant or business entity intend to file an additional application for a dispensary ficense under the same or a different mame at in? LEs0, please provide the location(s} and any other name under whith ill be made, Dispensary. LL ol subi al her in any 8, Iethe Applicant or any owner, stockholder, shareholder, officer, or board my way am ny other applicantsts) for dispeusarieséeultivation centers? Uf adividoal snd the name of the proposed! cultivation Tacility or Ay deseribe the mature of the rekitionshi ce Ue tial pave with aussie iw Secsion AB) Covtitication corti that the information, prs idea in this tron jeje and accurate. |waderstand that any misstatement or ceneealment of Eret may be ground for relisal of applivation or revavation of license iF later disclose, Signa this hay of Subsecibyd and sworn to before mye this sof Notary Public My Comission Expires:SECTION A. PAGE 003 DISPENSARY APPLICATION | SECTION A. GENERAL INFORMATION, #8 00 \Z 4#8, Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) for dispensaries/eultivation centers? If yes, please tdentily the individual and the name of the proposed facility or dispensary, and briefly describe the nature of the relationship? The following individuals are affiliated with Natural State W two cultivation applications with locations proposed in Jefferson County and Jackson County) and Natural State Wetlness Dispensary, LLC (submitting six dispensary applications with locations proposed in Little Rock, Jonesboro, Fort Smith, and Pine Bluff) Named Applicant end Owner ness Enterprises, LLC (submitting ‘Owner Owne! Owner (note: only an owner of Naturat State Wellness Dispensary, LLC) 5 Owner 6 -Owner 7 Owner Owner Owner | Owner’ Manager LLC aad both ferson County and Jackson ness Enterprises, with proposed locations in cultivation applicatic 1, ES — Srred Applicare 15 oyner and Owner i6 Owmer - Owner 7 -Owner for that compan; 3 - Owner | Owner 4. - Owner er 5 ner Owner = Owner - Owner Neuropsychologist = Owner/Manager ° 2SECTION A. PAGE 004 0017" Certification | MN cif tht che information provided inthis form (Section A) and its atachments is complete and accurate, I understand that eny misstatement or concealment of feet may be grounds for refusal of application or revocation of license if later disclosed. Signed his /2* day of Sep Signaturé of Applicant and sworn to before me this [25 _day of September, 2017. f nélan 4 (Kbfalo 0 Notary Public My Comunission Expires: (92 -[I-OZ? APPLICATION FOR MEDICAL MARIJUANA DISPENSARY IN. RAL INFORMATION 1, Name of Applicant (aust be a natal person.) mmm 2. Business Name _NCD Group LLC 1s Trade Name (if any|_AR Wellness Sol Mailing Adress III tle Rock, AR 72209 a Business telephne number _501-580-6485 3. Business entity (ype Dispensary Dste of business formation o° incorporation_7/18/2017 State(s) of Incorporation _ Arkansas Registered Agent Name _Gil Ragan Owen, P. Registered Agent Address 425 West Gavitol, Suite 3800, Lite Rack, AR 72201 4. List all owners, stockholders, sharebolers, aed proposed dispensary, Identity the nature of th wropased dispensary aad per sure that 100% of dhe ownership tnt section, (Athneh any necessary satdlitionat pages to this form, Include a be is response should ‘nelude "Section A. Numbers") I | 0-76: and Chie! Exocutive Oficer, 35.55% ownership [ENN | Ovrer ond Chie? Operating Oficer, 30% ownership = Owner and Chief Mectcat Officer, 24.49 % OwnSTSNID ‘Owner and Chie® Financial Officer, Sy ownership I — ©0027 rd Chie’ Dspensary Officer, 5% ownership «Clie! Tectnoogy Otfcar I © e! Strategy Officer attachments, ‘The header 7 3. Canty of Proposed Location Pulaski 6. City of Proposed Location (ifinside city limits) Little RockOALF business entity fled, or does the applicant or business entity intend pplication for u dispensary license under the sam or a different name at dany other name under h 8. Isthe Applicant or any owner, stockholder, shareholde way affiliated with any otiver appticants(s) for dispensariesieultivation centers? Ifyes, please identify the individual and the name af the proposed eultiv dispensary, and briefly deseribe the nature uf the relationship, officer, or board member in any fan facility ar No ertiieation a oar tha he information provided in this fem and is attachments is complete and acewate. J understand that any misstatement or concealment of fuck may be urounds or refusal of applisation or revocation of license if later disclosed, Signed this 12th day of _September me ._2017 A Signature of Applicant | Q _ sateorned ni swore rete mens LZ" aye Depleyhee 201% funn &. Usdhan Notary Public My Commission Expires:60120 APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY SECTION A. GENERAL INFORMATION 1, Name of Applicant (Must be a natural person.) ——E_ EEC Business Name Independence Investments LLC Fictitious Trade Name (if any) Business Mailing Address mmm Batesville, AR 72501 Business telephone number 1-870-793-3400 3. Business entity type BEC Date of bu css formation or incorporation__9-t6-2002 State(s) of Incorporation Arkansas Registered Agent Name__The Corporation Company Registered Agent Address__425 West Capitol Ave ,Ste 1700 Little Rock, AR 72201COolSoO 4, List all owners, stockholders, shareholders, members, officers, and board members of ihe 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. Inchide a header on any attachments. ‘The header for this response should include “Section A. Number 4.") GE 100%. ownership . County of Proposed Location__ Jackson 6. City of Proposed Location ([f inside city limits)__ Newport 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 a different name at a different location? If so, please provide the location(s) and any other name under whieh the application(s) will be made. Ko. 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) forQOISO 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. No _, certify that the information provided in this concealment of fact may be grounds for refusal of application or revocation of license if later disclosed. Signed this 8 My Commission Expires taouas «| otary Public ~ Comme 12384925 My Commision Eapiras Sep 24, 2021OO)/S) APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY SI (ORMA’ ION A. 1, Name of Applicant (Must be a natural person.) 5 e Business Name Naturalis Health, LLC Fictitious Trade Name (if any) Naturalis Health Business Mailing Address Little Rock, AR 72208 Business telephone number 501-270-8104 . Business entity type Limited Liability Company Date of business formation or incorporation May 24, 2017 Arkansas Henry P. Willmuth Registered Agent Address 2200 Commercial Ln. LR, AR 72206 State(s) of Incorporation Registered Agent NameOO| SB 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, if any. NOTE: Please make sure that 106% 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.”) Ouner Board Member 35.75% equity Owner / Board Member 35.75% eauly Aig TE ne (Grier crecutive Oficer/ Board Member 15% eauly | Ownas { Chief Retall Officer /Board Member 3.5% equity Owner! Chef Legal Offcer/ Board Member 5% eauily 700% equity ley: Chief Operations Officer Oi equity de Chief Financial Officer 0% equily 7 7 Chief Security Oficer 0% eauity | Grief Medical Officer 0% eauily 5. County of Proposed Location_Pulaski County’ 6. City of Proposed Location ([finside city limits)_titte Rook 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 a different name at a different location? Ifso, please provide the location(s) and any other name under which the application(s) will be made. No tockholder, sharcholder, officer, or any other applicant(s) for 8, Is the Appl board member in any way affiliatedOO1D| dispensaries/cultivation centers? If yes, please identify the i the namie of the proposed cultivation facility or dispensary, and briefly deserihe the nature of the relationship. No _ a Metis tsi intormation provided ni form and ifs attachm s complete and accurate. | understand that any misstatement or conceal ment of fact may be grounds for refusal of application or revocation of license if Later disclosed ned this [| DEN day of _ ature of Applicant tayo September Subseribed and swom to before me this /3. 2017 My Commission Expires, _/0- /- 2017._- 00\ SZ Name of Applicant (Must be a natural person.) Business Name 4 investment Fictitious Trad Batesville, AR 72501_ Name (if any), Business telephone number 1-870-793-3400 Business entity type ___ELC Date of business fornia 9-16-2002 jon oF incorporation Stateis) of Incorpora on Arkansas ‘orporation Company Registered Agent Adress 425 West Capitol Ave, Ste 1700 Little Rock, aR 72201 Registered Agent Nam Th List all owners, stockholders, shareholders, members, officers, and hoard members of th proposed! dispensary. (dentify the nature of the individual's or corporation's aff with the proposed dispensary and percentage of ownership, ifany. N Please make sure that 100% of the ownership interest in the proposed dispensary is accounted for in this section, (Attach any necessary alditional pages to this f alachments, The hear for this response shoukt inctuxke “Section A, Number 4°) elude i header on ay County of Proposed Location Independence ry Batesville ity of Proposed Location (If inside cityiN “Zz. 2 OO\S 7. Has the applicant or business entity Med, oF does the applicant or business entity intend to filean additional application for acispensary license under the sime or a different name at a different location? Ifso, please provide the location(s) a me under which {te apyigation(s) sill be made any other Is thy Applicant or any owner, stockhotder, shareholder, officer, or boxrd member in way affitiated with any other applicanis(s) for dispeasaries/eultivation centers? ITyes, please ideatity the individua) sind the name of the proposed cultivation Facility or ry, and briefly describe the nature of the relationship, No Cemtifieation | es anil ils atlachavents is completg and avenrate, Fanderstand that any misstaienwnt oF eon nay BY grounds for zetusal eP-applicalion or revocation of livense i later disekosed thal the information provides in this torm ant of le UT? tay or_S. - 2017. Signed this My Convnission Expires: BRANDY ALLWHITE Areanans-Indepencinct County Notary Pubhe - Comme 12384925 My Commission Expires Sap 24, 2021OOIS5 APPLICATION FOR MEDICAL MARIJUANA DISPENSARY ION A. GEN si pticant (Must bea natural person.) 2. Business Name \Jo\enting Walehings, Lc. a Fictitious Trade Name (if any) AL INFORMATION Business M ___ Soneshare AK Vay 7 ber BID AYV3-TLO) type Liga ted Liab Nets Coop, _ or incorporation, Agal lo, QOY State(s) of incorporation Ac KANSAS, I Register Agent Nawe “Wooaid L.Casver IE Registered Avent Address 3000 Browns Lane. eneshnere ADO Business telephone Business en Date of business fori 4. List all owners, stockholders, shareholders, members, offic proposed dispens: with the proposed dispensa sure that 100 section. (Attach any necessary slditional p attachments, ‘The header for this response should include -Owner = Da.33aHb. and percentage of ownership, if any. NOTE: Please make cerest in the proposed dispensary is accounted fo wes to this Form. Include a healer on any jection A. Number 4.") S. County of Proposed Location Sebastian County a 6 Cy of Proposed Location (If'inside city limits) For Sant.OO\SS 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 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicants(s) for dispensaries/eultivation centers? If yes, please identify the individual and the name of the proposed cultivation faci dispensary, and briefly describe the nature of the relationship. Le, tv \atca in Siteson Court Arkon sts Nalentine Witting? (SUG 15 6. "Io. fant at Dein ted Cannas Gangoayibee " = Cenification certify that the information provided complete and accurate, Tuaderstand that any misstatement or cone’ may be grounds for refusal of application or revocation of license if later disclosed Signed this \DOS _ aay of _Seohemner » O01 Sienature oP AppHeane Subscribed and swom to betire me this YOO aay of Sepremoer ow) _Whpinaha Who Oe $ Notary Publie - My Commission Expires: \\N1=302'0 an maoomconny My commen Emcee 17-2008 Gonminiane (nieOO \>Y APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION Nameof i pcisun.) ERAL INFORMATION 2. Business Name __Danclegs Gorew LIE, Fictitious Trude Name (iC any) Dandy * = Garden buinss sane aces EA West fork AR gar Business telephone number__ 4479+ 530-4S)0 3 wpe ALO _ - - Date of business formation or ineorpor September 2 20/7 State(9) of tncorporation Ae Kansas Registered Agent Name Sharen Le av Registered Agen: Address 27Y¥00 S, Hwy, 170 West fork AR BI 4. List all owners, stockholders, shareholders, anembers. officers, and board members of the proposed dispensary. Identify the nature ofthe individual's ar corpora ‘ith the proposed dispensary aod persentage of visnershlp, any. NOTR: Please make sure that 100% of the ownership interest in the proposed dispensary is accounted for in this section. (Attach any necessary additonal pages ts this form, Inchuge a header on any aituchients. The header fortis respone should inchide"Seetion A. Number + — Bo _——_ - J 2 & County of Proposed Location Washing fen C10 City of Proposed Location (ifinside city limits) Fay ettev- lle, AROC\SY 7. Has the applicant or business entity filed. or does the applicant or business entity intend to an additional application for a dispensary license under the same or a different nanie at a different location? If so, please provide the location(s) and any other name under which happenings wi bem es Ovata de ake County | 8. Is ithe Applicant or any owner. stockholder, shareholder, officer. or board member in way affiliated with any other applicants(s) for dispensaries/cultivation centers? IF yes. please identify the individual and the name of the proposed cultivation dispensary, and briefly describe the nature of the relationship Cenification certify that U Tunderstand that any’ misstatement or concealment o} and its cftachments is complete and ae may’ be grounds for refusal of appl baie OE ay a Signature of Applicant [Say ot I _30In Subscribed and sworn to before me this, My Commission Eapires: O|-O2— 20771 “in Pui00\25 APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. GENERAL INFORMATION 1, Name of Applicant (Must be a natural person.) = 2. Bu yess Name Naturalis Heath, LC Fictitious Trade Name (if any) Naurats Heath ess Mailing Address MIMI 8s Rock Ackanens 72z06 Bu Business telephone number 501-270-8108 3. Business entity type Limited Uablity Company Date of business fo ation or incorporation May 24.2017 State(s) of Incorporation Arkansas Registered Agent Name Horry P. vsimun Registered Agen! Address 2200 Commer Ln. Lita Rack, Artanta 72206 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 awnership, 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 for, Include a header on any attachments, The header for this response should include “Section A. Number 4.") [Owner Board Member Yat Executive Officer Board Meniber wn 15% equly (Quner/ Gret Reta Ofer /Boare Mernber 5% equty Guner/ Chief Lage OFicer/ Board Member 100% equity (Ghia! Operations Of Oi saul Ciel Financial Offesr 0% eauly Ove eauy (Che! Security Ofer Chit Mosicl Offer OH eauiy 5. County of Proposed Location _Pulaski County 6. City of Proposed Location (inside city limits) Ute RoekOSS 7. Mas the applicant ar business entity filed, or docs the applicant oF business entity intend to file an additional application for a dispensary license under the same or a differemt mame at a different location’ If so please provide the lacation(s) and any other name wader whieh the application(s) will be made. way affiliated with any other applicants(s) for dispensarieseultiv please identify the individual and the wame of the propased cultivation tax dispensary, and briefly describe the n provided in this Torn nent of Fact ‘cortfy that the information and its aftachmenis is complete and accurate, | understand thot any’ misstalcment or concoa niay ho grounds for refusal of application or revocation of ligerse if later disclosed signet his 14 day or _ Sepernbre— DOT Signature of Applicant ay of Septembere Rol7 Subscribed and swom to before me this _ 13 My Commission Expires: JO-/- 2017O0\Se APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. GENERAL INFORMATION 1, Namte of Applicant (Must be a natural person.) 2, Business Name __Neclar Markets of Arkansas, LLC Fictitious Trade Name (if ary) N/A Business Mailing Address Portland, OR 97232 Business telephone number _ (971) 705-4777 ability 3. Business entity type _Limived Date of business formation or incorporation August 1], 2017 State(s) of Incorporation ___ Arkin Registered Agent Name ___ Corporation Servive Company Registered Agent Address __ 300 Spring building, Suite 990. 300 Spring Stree Little Reck, AR. 72201 4. List all owners, stockholders, shareholders, members, officers, and buard 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 sare that 109% of the ownership interest in the proposed dispensary is accounted for in this section, (Aue any necessary additional pages to this form. Include a header on any attachments. The header for this response should include “Section A. Number 4.°) MI = 60°20 «ner in Nevtar Markots of Arkansas, LLC TRS | 27 250 ner ang CEO of Nectar ashes of Arkansas LC ~ 3% Owner and COO of Nestar Markets of Arkansas, LUC ME | CO ee 5. County of Proposed Lecation “PUMASYc 6. City of Proposed Location rinsideciy tints Levttle Rock0/36 Has the applicant or business entity filed, or does the applicant or business en file an additional application for a dispensary license under the same or a different name at a different loc and any other name under which ion? [T$0, please provide the locatio Is the Applicant or any owner, stackholder, sharcholder, officer, or board member in any way affiliated with any other applicants(s) for dispensaries‘cultivation centers? Ives, please identify the individual and the name of the proposed enitiva dispensary, and briefly describe the nature of the relationship. {Arkansas LLC are also owners of Applevate Valley Organics submitting taultiple applivations for dispensary and ation tify that the information provided in this form d that any missterement or concealment of fact and) may be grounds for refusal of application or revacatton of license if later disclosed. Siuned this \= My Commission Expires: ob -dhDISPENSARY APPLICATION "DRS SECTION, A SUBPART GENERAL INFORMATION OO|>7 APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. GENERAL INFORMATION 1, Name of Applicant (Must be @ natural person.) 2. Business Name _ Desert River Services, LLC. Fictitio Business Mailing Address (IMM hoenix AZ 85004 Trade Name (if any), Business telephone number __ 602-595-6873 inate enti ee: Limited Liability Company "LLC" \corporation__ 8/11/2017 Date of business formation of > State(s) of Incorporation Aransas Registered Agent Name____—— Registered Agents,Inc Registered Agent Address 701 South St, Ste 100 Mountain Home AZ 72653 List all owners, stockholders, shareholders, members, officers, and hoard 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 amy. 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 header for this response should include “Section A. Number 4.") licant, Owner 60% 5. County of Proposed Location Pulaski 6. City of Proposed Location (Ifinside city timits)_ _North Little RockDISPENSARY APPLICATION "DRS" SECTION =A SUBPART Gl C0(|37 2. Has the applicant or business entity fled, or dacs th applicant or basinem entity intend to file an additonal application fora dispensary lease under the same ora different name a ¢ diferent location? Ifo, please provide the loention(} and any ather uame under which the applications willbe made, No. ENERAL INFORMATION 8, Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicants(s) for dispensaries/eultivation 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. None of the applicents are involved in any other Dispensary application Trowever all of the applicants as an identically comprised group are submitting a separate Cultivation license application. This group of applicants together Thave a great deal of experience operating both dispensary and cultivation businesses tification as . certify that the information provided in this form ani its attachments is complete and accuraie. I understand that any misstatement or concealment of faci may be grounds for refusal of application or revocation of license if later disclosed ( signed his_ ZL day of sa Subserited and sworn to before me this__|B dey of bee 22 Vavnane Meliortin Notary Public My Commission Expires: 1d TAMARA JACKSON Novy LRA Specs hy connsn Ce Fa sen Bey ry 14,202300/38 APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY SECTION A, GENERAL INFORMATION 1, Name of Applicant (Must be « natural person.) jiness Name Grassroots OpCo AR. LLC. jous Trade Name (if any), Business Mailing Addres Proposed Location Aces: I telephone n Bu Business entity type wd Liability Company Date of business formation or incorporation__Auywst 17.2017 State(s) of Incorporation _ Arkansas Re istered Ag tf Name __ Corporation Services Company 300 Seuth Sping Str, Spring Building, Seite 000 {ule Rode, Arkiesis 72201 Registered Agemt AddressO0;D& 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 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.") 10.20% 20,100%6 PIB otsines ansncve 1.0 073% Livnoih own by the Cop's CO PCCW Investments, LLC 4.075%» (Owned phe Compan 's C00 7 6 Poristig imveumens, LLC 1 sp0% (Ovvnad by finanelal backer ) VOTAL___101,000% 5. County of Proposed Location_Sharp_ 6. City of Proposed Location (If inside city limits)__Walliford _ 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 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, off board member in any way affiliated with any other applicant(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, the Company has also applied for dispensary licenses under the same name, L certify that the information provided in this form and its atlachments is complete and accurate. | understand that any misstatement or concealment of fact may be grounds for refusal of application or revocation of license if later disclosed. Signed this_/ ] \Wth___day of _ Sealemper prorersry00137 APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. ERAL INFORMATION 1. Name of Applicant (Must be a natural person.) 2, Business Name Northwest Arkansas Solutions, LLC Fictitious Trade Name (ifany) Business Mailing Address Bentonville, AR 72712 Business telephone number 479-640-4699 Business entity type Dispensary Facility July, 30 2017 1 of business formation or incorporation, State(s) of Incorporation Atkansas Registered Agent Name Repistered Agent Address 4. Listall owners, stockholders, shareholders, members, officers, and board members of the proposed dispensary. Identify the nuture of the individual's or corporation's affiliation with the proposed dispensary und 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 som. Include a beader on any attachments. ‘The header for this response should include “Section A. Number 4.") MEE 20%, ownership 40% ownershil 20% ovinershi 3 junty of Propased Location Benton County 6. City of Proposed Location (inside city limits)_Bentorville, AR7. Has the applicant or business entity flled, or does the applicant or business 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 the application(s) will be made. No 8. Is the Applicant or any owner, stockholder, sharcholder, 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 facil dispensary, and briefly deseribe the nature of the relationship. No . certify that the information provided in this form. and is attachments is complete and accukRe stand that any misstatement or concealment of fact ‘may be grounds for refusal of application or revocation of license if later disclosed, Signed inis 1 " day 0} Suber an worn ttifoenim ic _! 4 @— Opp ako. My Commission Expires