Form - OCC - GJCBL - Cannabis - #0008 Addendum Authorization Supplementals

REGULATED CANNABIS BUSINESS LICENSE

CITY OF GRAND JUNCTION PERSONAL HISTORY ADDENDUM

The City of Grand Junction requires additional, more stringent criteria for determining the acceptability as a licensee. Please answer the following questions in addition to similar questions in the State Finding of Suitability.

(Owner Information) Cannabis Business Entity Name:___________________________________________________

Applicant’s Name (Last, First)	Home Address		Date of Birth (mm/dd/yyyy) ____/____/______
Phone Number(s)	Email Address		% Ownership
Social Security Number	Driver’s License Number		Driver’s License State
Within the 5 years immediately preceding this application, have you been convicted of any misdemeanor, petty offense or local ordinance related to a drug or controlled substance offense? Within the 5 years immediately preceding this application, have you been convicted of any non-drug related felony? At any time, have you been convicted of a drug or controlled substance felony? Within the 5 years immediately preceding this application, have you been released from incarceration or court-ordered supervision, including a deferred sentence, for a conviction of any felony or crime that would be a felony in Colorado? At any time, have you been convicted of any crime of which fraud or intent to defraud was an element of the offense? IF YOU ANSWERED YES TO ANY OF THE ABOVE, COMPLETE ATTACHED CRIMINAL HISTORY SUPPLMENTAL SHEET		Yes No ________Initials Yes No ________Initials Yes No ________Initials Yes No ________Initials Yes No ________Initials
Have you ever had a professional or occupational license denied, suspended or revoked? Have you ever had a business or sales tax license denied, suspended or revoked? Have you ever surrendered, been denied, or had any type of cannabis related license or permit placed on an administrative hold, suspended or revoked? Have you ever been denied any type of cannabis related business license? Have you ever had a business temporarily or permanently closed for failure to comply with any tax, health, building, fire, zoning or safety law? Have you ever had any administrative, civil or criminal finding of delinquency for failure to file or failure to pay state or local sales or use taxes or any other taxes? IF YOU ANSWERED YES TO ANY OF THE ABOVE, COMPLETE ATTACHED LICENSE DISCIPLINE HISTORY SUPPLEMENTAL SHEET		Yes No ________Initials Yes No ________Initials Yes No ________Initials Yes No ________Initials Yes No ________Initials Yes No ________Initials

Have you ever been arrested, served with a criminal summons, charged with, or convicted of any crime or offense in any manner in this or any other state?

• You must include all arrests, charges and convictions regardless of the outcome, even if the charges were dismissed or you were found not guilty.

• You must include all arrests, charges and convictions regardless of the class of the crime (felonies, misdemeanors and/or petty offenses).

• You must include all serious traffic offenses, including DUI, DWAI, reckless driving, leaving the scene of an accident, driving under suspension, revocation or denial, or any other offense which resulted in you being taken into custody or served with a summons into Court.

NOTICE: Do not rely upon your understanding that an arrest or charge is “not supposed to be on my record.” A criminal record was not cleared, erased, sealed or expunged unless you were given, and have in your possession, a written order from a Judge directing that action.

IF YOU ANSWERED YES ABOVE, COMPLETE ATTACHED CRIMINAL HISTORY SUPPLEMENTAL SHEET

Yes No ________Initials

Have you (as an individual, as a member of a partnership or other form of domestic or foreign business entity, or as an owner, director, or officer of a corporation) ever been a party to a lawsuit (other than divorces) either as a plaintiff or defendant, complainant or respondent, or in any other fashion, in this or any other state? This includes all civil litigation, regardless of the type of lawsuit or the Court of jurisdiction. List all cases without exception, including bankruptcies, liens and cases in Small Claims Courts.

IF YOU ANSWERED YES ABOVE, COMPLETE ATTACHED CIVIL LITIGATION HISTORY SUPPLEMENTAL SHEET

Yes No ________Initials

If you answered “YES” to any of the questions, explain in detail on the attached supplemental history sheet(s). For each offense for which you were arrested or charged, YOU MUST OBTAIN OFFICIAL DOCUMENTATION FROM THE COURT WHERE YOU APPEARED, SHOWING THE FINAL DISPOSITION (OUTCOME) OF YOUR CASE. If you received a deferred judgment, a deferred sentence or probation, your documentation must include the date that you were discharged or released from probation or other supervision.

On the attached supplemental license data history sheet, list all locations where you have had a professional, occupational, business or sales tax license, where you have owned and/or operated a business and the name of your business(es).

If you were in the Armed Forces, please complete the attached Military history supplemental sheet.

I attest that all information I have provided on this Addendum and supplemental documents is true and accurate to the best of my knowledge and acknowledge any omissions and/or falsifications may result in denial or revocation of a regulated cannabis license.

__________________________________|_____/_____/_____

(Signature) (Date)

INVESTIGATION AUTHORIZATION / AUTHORIZATION TO RELEASE INFORMATION

I, _____________________________________________, hereby authorize the City of Grand Junction, the City of Grand Junction Licensing Authority and the City of Grand Junction Police Department (hereafter, the Investigatory Agencies) to conduct a complete investigation into my personal background, using whatever legal means they deem appropriate. I hereby authorize any person or entity contacted by the Investigatory Agencies to provide any and all such information deemed necessary by the Investigatory Agencies. I hereby waive any rights of confidentiality in this regard. I understand that by signing this authorization, a financial record check may be performed. I authorize any financial institution to surrender to the Investigatory Agencies a complete and accurate record of such transactions that may have occurred with that institution, including, but not limited to, internal banking memoranda, past and present loan applications, financial statements and any other documents relating to my personal or business financial records in whatever form and wherever located. I authorize the release of this type of information, even though such information may be designated as “confidential” or “nonpublic” under the provisions of state or federal laws.

I understand that by signing this authorization a criminal history check will be performed. I authorize the Investigatory Agencies to obtain and use from any source, any information concerning me contained in any type of criminal history record files, wherever located. I understand that the criminal history record files contain records of arrests which may have resulted in a disposition other than a finding of guilt. I understand that the information may contain listings of charges that resulted in suspended imposition of sentence, even though I successfully completed the conditions of said sentence and was discharged pursuant to law. I authorize the release of this type of information, even though this record may be designated as “confidential” or “nonpublic” under the provisions of state or federal laws.

The Investigatory Agencies reserve the right to investigate all relevant information and facts to their satisfaction. I understand that the Investigatory Agencies may conduct a complete and comprehensive investigation to determine the accuracy of all information gathered. However, the City of Grand Junction, Investigatory Agencies, and other agents or employees of the City of Grand Junction shall not be held liable for the receipt, use or dissemination of inaccurate information. I, on behalf of the applicant, its legal representatives, and assigns, hereby release, waive, discharge and agree to hold harmless, and otherwise waive liability as to the City of Grand Junction, Investigatory Agencies, and other agents or employees of the City of Grand Junction for any damages resulting from any use, disclosure, or publication in any manner, other than a willfully unlawful disclosure or publication, of any material or information acquired during inquiries, investigations, or hearings, and hereby authorize the lawful use, disclosure, or publication of this material or information. Any information contained within my application, contained within any financial or personnel record, or otherwise found, obtained, or maintained by the Investigatory Agencies, shall be accessible to Law Enforcement agents of this or any other state or the government of the United States.

PRINT FULL LEGAL NAME OF OWNER CLEARLY BELOW:
Applicant’s Legal Business Name		Trade Name (DBA)
Applicant’s Last Name (Please Print)	Applicant’s First Name	Applicant’s Middle Name		Applicant’s Date of Birth
Signature (Notarized)			Date

NOTARY PUBLIC

State of ____ ____County of ________

Subscribed and Sworn to before me this day of ______,20____

Notary Public ________

My Commission Expires ________

City of Grand Junction Criminal History Supplemental Sheet

Date Charge City County State Court Case Number

Details Including Disposition/Outcome:

Date Charge City County State Court Case Number

Details Including Disposition/Outcome:

Date Charge City County State Court Case Number

Details Including Disposition/Outcome:

Date Charge City County State Court Case Number

Details Including Disposition/Outcome:

Date Charge City County State Court Case Number

Details Including Disposition/Outcome:

City of Grand Junction License Data History Supplemental Sheet