Form CDPH-9039A Annual License Application: Cannabis Manufacturing - Owner Information - California

Form CDPH-9039A or the "Annual License Application: Cannabis Manufacturing - Owner Information" is a form issued by the California Department of Public Health.

Download a PDF version of the Form CDPH-9039A down below or find it on the California Department of Public Health Forms website.

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 
State of California – Health and Human Services Agency
California Department of Public Health
Manufactured Cannabis Safety Branch
Annual License Application: Cannabis Manufacturing - Owner Information
SECTION A – OWNER INFORMATION –
Each owner of the company, as defined in Title 17, Section
40102 of the California Code of Regulations, must complete and sign this form.
First Name
MI
Last Name
Social Security Number
Individual Tax ID Number (If Applicable)
Date of Birth
Job Title
Primary Phone Number
Secondary Phone Number
Email Address
Type of Address:
Mailing
Home
Work
Address
City
State
Zip
County
SECTION B – LIVE SCAN –
Please enter the Live Scan information for the owner identified in Section A.
Fingerprint Date
Live Scan ATI Number
Check here to confirm that you have attached a copy of the completed “Request for Live Scan” form (BCIA 8016)
SECTION C – DISCLOSURES –
Please check all that apply for the owner identified in Section A. Prior
convictions do not lead to automatic denial of a license. Include a description of the circumstance of the conviction
and any evidence of rehabilitation that you wish the Department to consider when evaluating your application
(Section 40165)
Yes
1. Have you ever been convicted of a crime (excluding infractions or juvenile adjudications)?
No
2.
Have you ever received a fine or penalty for cultivation or production of a controlled
Yes
No
substance on public or private land?
Have you been subject to sanctions or denied a license by a state licensing authority or a
3.
Yes
No
city or county for unlicensed or unauthorized commercial cannabis activity within the last
three years?
4.
Yes
No
Have you been convicted of an offense or been found responsible for a violation of food
and product safety laws as specified in Title 17, CCR, Section 40162?
5.
Have you had a commercial cannabis license suspended or revoked by a licensing
Yes
No
authority or local jurisdiction within the last three years?
6.
If you answered “yes” to any question, is evidence of rehabilitation and/or a description of
Yes
No
the circumstances attached?
SECTION D – ATTESTATION
I declare under penalty of perjury that the information in this application, including the statements herein
and attachments hereto, are complete, true, and accurate. BPC § 26051.5(a)(4).
Signature of Owner
Print Name
Date
CDPH-9039A (01/18)
 
State of California – Health and Human Services Agency
California Department of Public Health
Manufactured Cannabis Safety Branch
Annual License Application: Cannabis Manufacturing - Owner Information
SECTION A – OWNER INFORMATION –
Each owner of the company, as defined in Title 17, Section
40102 of the California Code of Regulations, must complete and sign this form.
First Name
MI
Last Name
Social Security Number
Individual Tax ID Number (If Applicable)
Date of Birth
Job Title
Primary Phone Number
Secondary Phone Number
Email Address
Type of Address:
Mailing
Home
Work
Address
City
State
Zip
County
SECTION B – LIVE SCAN –
Please enter the Live Scan information for the owner identified in Section A.
Fingerprint Date
Live Scan ATI Number
Check here to confirm that you have attached a copy of the completed “Request for Live Scan” form (BCIA 8016)
SECTION C – DISCLOSURES –
Please check all that apply for the owner identified in Section A. Prior
convictions do not lead to automatic denial of a license. Include a description of the circumstance of the conviction
and any evidence of rehabilitation that you wish the Department to consider when evaluating your application
(Section 40165)
Yes
1. Have you ever been convicted of a crime (excluding infractions or juvenile adjudications)?
No
2.
Have you ever received a fine or penalty for cultivation or production of a controlled
Yes
No
substance on public or private land?
Have you been subject to sanctions or denied a license by a state licensing authority or a
3.
Yes
No
city or county for unlicensed or unauthorized commercial cannabis activity within the last
three years?
4.
Yes
No
Have you been convicted of an offense or been found responsible for a violation of food
and product safety laws as specified in Title 17, CCR, Section 40162?
5.
Have you had a commercial cannabis license suspended or revoked by a licensing
Yes
No
authority or local jurisdiction within the last three years?
6.
If you answered “yes” to any question, is evidence of rehabilitation and/or a description of
Yes
No
the circumstances attached?
SECTION D – ATTESTATION
I declare under penalty of perjury that the information in this application, including the statements herein
and attachments hereto, are complete, true, and accurate. BPC § 26051.5(a)(4).
Signature of Owner
Print Name
Date
CDPH-9039A (01/18)

Download Form CDPH-9039A Annual License Application: Cannabis Manufacturing - Owner Information - California

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