Form AG-03390 "Hemp Program License Change Request" - Minnesota

What Is Form AG-03390?

This is a legal form that was released by the Minnesota Department of Agriculture - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Minnesota Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AG-03390 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG-03390 "Hemp Program License Change Request" - Minnesota

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625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PLANT PROTECTION DIVISION
Phone: 651-201-6600
Minnesota Statute 18K
HEMP PROGRAM LICENSE CHANGE REQUEST
Tennessen Warning and Social Security Number Collection Notice
The information/data provided as part of this application will be used by MDA staff to assess applicants’ eligibility to be licensed under the MDA Hemp Program. All
applicants are required by Minnesota Statutes, Chapter 18K to provide the information requested in this form; incomplete or inaccurate applications may result in a delay
in the processing of an application or the denial of a license. Minnesota law requires that all licensing authorities collect the social security number and Minnesota
business tax identification number of all applicants (Minnesota Statutes, Section 270C.72). Applicant information, including social security numbers and Minnesota
business tax identification numbers, will be provided to the Minnesota Department of Revenue upon request. Under the Federal Exchange of Information Agreement, the
Department of Revenue may provide the data to the Internal Revenue Service. Social security numbers and Minnesota business tax identification numbers may be used to
deny the issuance, renewal or transfer of a license in the event an applicant or licensee owes the Department of Revenue delinquent taxes, penalties or interest. As a
participant in the Industrial Hemp program, some data provided on this application (including social security numbers) are classified under Minnesota law as private or
nonpublic. At the MDA, data classified as private or nonpublic will be viewed and used only by authorized employees and contractors that require access to perform a valid
work assignment. Unless you consent to its release, sharing of private and nonpublic data will be limited to other entities authorized by law to receive the
information and parties named in a valid court order or federal subpoena. By law, MDA may share private and nonpublic information with local, state or federal law
enforcement, including the Minnesota Department of Public Safety, if MDA determines that such sharing would aid in the law enforcement process. MDA may be
required to share the information with the Department of Revenue, the Internal Revenue Service, the Office of the Legislative Auditor or the Office of the State Auditor
upon their request. In addition, private or nonpublic data may be shared with other government entities or made public if the MDA determines that there is a substantive
threat to human health and safety or to the environment. In the event of a legal action, your information may be shared with the Minnesota Office of the Attorney General
and possibly presented as evidence in court. Notice to all applicants: the MDA Hemp Pilot Program, as authorized under Minn. Stat. 18k.09 will expire on December 31,
2020. This Change Request form is for a commercial Hemp Program license, operating under the USDA-approved Minnesota state hemp plan and Minn. Stat. 18K.
Questions? Please contact MDA at 651-201-6600 or hemp.mda@state.mn.us
PART 1 – LICENSE CHANGE INFORMATION
License Number
Licensee Name
Contact Phone Number
Change Request Date
Minnesota Tax ID Number
Change in license name:
New License Name
or Social Security Number
Addition of license category
(please complete the location information for the new license type on page 2):
Hemp Processor License
Hemp Grower License
Change in grower or processing location
(please select the change type below and complete the location information on page 2):
Hemp Field/Grow Location Changes
Hemp Processor Location Changes
Change in existing grow location
Change in existing processing location
Addition of new grow location
Addition of new processing location
Part 2 – LICENSE CHANGE FEE CALCULATOR
All License Changes incur a $50 change fee. Make check or money order payable to Minnesota Department of Agriculture or MDA. Check, cash, or credit card payments may be made in person with an appointment. Fees are non-refundable.
1
I am adding a Grower License Category
$150
600546(3100)
$
I am adding a Grow Location
2
$250
600548(3200)
$
I am adding a Processor License Category
3
$250
NOTE: there is no charge for additional processor locations if you hold a processor license
600555(3100)
$
4
Change Fee
$50
$
600546(3100)
TOTAL FEES DUE (Add lines 1-4) $
Return this form with your check or money order made payable to:
Office Use Only
Minnesota Department of
Agriculture Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
AG-03390 (10/20)
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
Page 1 of 2
625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PLANT PROTECTION DIVISION
Phone: 651-201-6600
Minnesota Statute 18K
HEMP PROGRAM LICENSE CHANGE REQUEST
Tennessen Warning and Social Security Number Collection Notice
The information/data provided as part of this application will be used by MDA staff to assess applicants’ eligibility to be licensed under the MDA Hemp Program. All
applicants are required by Minnesota Statutes, Chapter 18K to provide the information requested in this form; incomplete or inaccurate applications may result in a delay
in the processing of an application or the denial of a license. Minnesota law requires that all licensing authorities collect the social security number and Minnesota
business tax identification number of all applicants (Minnesota Statutes, Section 270C.72). Applicant information, including social security numbers and Minnesota
business tax identification numbers, will be provided to the Minnesota Department of Revenue upon request. Under the Federal Exchange of Information Agreement, the
Department of Revenue may provide the data to the Internal Revenue Service. Social security numbers and Minnesota business tax identification numbers may be used to
deny the issuance, renewal or transfer of a license in the event an applicant or licensee owes the Department of Revenue delinquent taxes, penalties or interest. As a
participant in the Industrial Hemp program, some data provided on this application (including social security numbers) are classified under Minnesota law as private or
nonpublic. At the MDA, data classified as private or nonpublic will be viewed and used only by authorized employees and contractors that require access to perform a valid
work assignment. Unless you consent to its release, sharing of private and nonpublic data will be limited to other entities authorized by law to receive the
information and parties named in a valid court order or federal subpoena. By law, MDA may share private and nonpublic information with local, state or federal law
enforcement, including the Minnesota Department of Public Safety, if MDA determines that such sharing would aid in the law enforcement process. MDA may be
required to share the information with the Department of Revenue, the Internal Revenue Service, the Office of the Legislative Auditor or the Office of the State Auditor
upon their request. In addition, private or nonpublic data may be shared with other government entities or made public if the MDA determines that there is a substantive
threat to human health and safety or to the environment. In the event of a legal action, your information may be shared with the Minnesota Office of the Attorney General
and possibly presented as evidence in court. Notice to all applicants: the MDA Hemp Pilot Program, as authorized under Minn. Stat. 18k.09 will expire on December 31,
2020. This Change Request form is for a commercial Hemp Program license, operating under the USDA-approved Minnesota state hemp plan and Minn. Stat. 18K.
Questions? Please contact MDA at 651-201-6600 or hemp.mda@state.mn.us
PART 1 – LICENSE CHANGE INFORMATION
License Number
Licensee Name
Contact Phone Number
Change Request Date
Minnesota Tax ID Number
Change in license name:
New License Name
or Social Security Number
Addition of license category
(please complete the location information for the new license type on page 2):
Hemp Processor License
Hemp Grower License
Change in grower or processing location
(please select the change type below and complete the location information on page 2):
Hemp Field/Grow Location Changes
Hemp Processor Location Changes
Change in existing grow location
Change in existing processing location
Addition of new grow location
Addition of new processing location
Part 2 – LICENSE CHANGE FEE CALCULATOR
All License Changes incur a $50 change fee. Make check or money order payable to Minnesota Department of Agriculture or MDA. Check, cash, or credit card payments may be made in person with an appointment. Fees are non-refundable.
1
I am adding a Grower License Category
$150
600546(3100)
$
I am adding a Grow Location
2
$250
600548(3200)
$
I am adding a Processor License Category
3
$250
NOTE: there is no charge for additional processor locations if you hold a processor license
600555(3100)
$
4
Change Fee
$50
$
600546(3100)
TOTAL FEES DUE (Add lines 1-4) $
Return this form with your check or money order made payable to:
Office Use Only
Minnesota Department of
Agriculture Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
AG-03390 (10/20)
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
Page 1 of 2
625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us
PLANT PROTECTION DIVISION
Phone: 651-201-6600
Minnesota Statute 18K
HEMP PROGRAM LICENSE CHANGE REQUEST
PART 3 – HEMP FIELD/GROW OR PROCESSING LOCATION CHANGE INFORMATION
Definitions
A Grow Location means a contiguous land area, or greenhouses, hoop houses, or buildings for indoor cultivation,
registered with the department, on which a Licensee will conduct licensed hemp cultivation activities. Each non-
contiguous grow location must be registered separately.
A Processing location means any area, building, plant,or facility registered with and approved by the department
in which a licensee will convert raw hemp plants or plant material into a marketable product for commercial
purposes.
NOTE: You may NOT process, store, or dry raw hemp in a residential dwelling.
New or Updated Location Information
Provide as much information for your updated location listed below as possible. (A detailed map must be submitted with this
form showing your updated location relevant to the nearest municipality and navigable roads). You may give either the legal
land description OR the GPS point AND the address.
Current Grow Location #
New Grow Location Information:
Change to Existing Location
Additional Location
Acreage/Indoor Square Feet
Indoor
Check One:
I
Outdoor
TWP
Range
Section
1/4 Section
GPS Point of Center of Grow Location
Latitude
Longitude
Grow Location Address
City
State
Zip
Grow Location Owner/Inhabitant, if different from the applicant
Name
Phone
Email
Current Processing Location #
New Processing Location Information:
Change to Existing Location
Additional Location
Section
1/4 Section
TWP
Range
Latitude
Longitude
GPS Point of Processing Location
City
State
Zip
Processing Location Address
Processing Location Owner/Inhabitant, if different from the applicant
Name
Phone
Email
AG-03390 (10/20)
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