Name of Applicant Corporation _________________________________

SECTION C. CHARACTER & COMPETENCY

This form must be completed and signed by each of the following actors: The Chief Executive Officer; Chief Operating Officer; Chief Financial Officer; individual/entity responsible for marijuana for medical use cultivation operations; individual/entity responsible for the RMD security plan and security operations; each member of the Board of Directors; each Member of the Corporation, if any; and each person and entity known to date that is committed to contributing 5% or more of initial capital to operate the proposed RMD. If the applicant does not have a Chief Executive Officer, Chief Operating Officer, or Chief Financial Officer, it must identify the individuals performing the equivalent duties for the applicant and submit this form for each said individual.

For entities contributing 5% or more of initial capital to operate the proposed RMD, this form must be completed and signed by the entity’s Chief Executive Officer or Executive Director and President or Chair of the Board of Directors. If the entity does not have a Chief Executive Officer or Executive Director or President or Chair of the Board of Directors, it must identify the individuals performing the equivalent duties for the entity and submit this form for each said individual.

Name of Individual

Title of Individual

Date of Birth of Individual

Residential Address of Individual

Name of Applicant Corporation

Answer “Yes” or “No” for each question. If you check “Yes,” please provide an explanation.

Have you ever been convicted of a felony drug offense in Massachusetts, or a like violation of the laws of another state, the United States, or a military, territorial, or Indian tribal authority?

Yes No If yes, please explain:

Have you been the subject of any legal or enforcement actions in any state, in the past or pending, related to the cultivation, processing, distribution, or sale of marijuana for medical purposes?

Yes No If yes, please explain:

Have you been the subject of any past or pending denial, suspension, or revocation of a license or registration, or the denial of a renewal of a license or registration, for any type of business or profession, by any federal, state, or local government, or any foreign jurisdiction, including denial, suspension, revocation, or refusal to renew certification for Medicaid or Medicare or failure to follow non-profit procedures or rules?

Yes No If yes, please explain:

Have you been the subject of any past discipline by, or a pending disciplinary action or unresolved complaint by, the Commonwealth, or a like action or complaint by another state, the United States or a military, territorial, or Indian tribal authority with regard to any professional license or registration?

Yes No If yes, please explain:

Have you been the subject of any investigation or discipline for prescribing or distributing controlled substances or legend drugs other than for therapeutic or other proper medical or scientific purposes?

Yes No If yes, please explain:

Has any entity in which you have served as an executive, officer, corporate member or board member been the subject of a correction order issued under the laws or regulations of the Commonwealth or other states, during the time that you were serving as an officer or board member?

Yes No If yes, please explain:

Has any entity in which you have served as an executive, officer, corporate member or board member been the subject of a governmental investigation or enforcement action for lack of compliance with laws of the Commonwealth relating to taxes and child support?

Yes No If yes, please explain:

Has any entity in which you have served as an executive, officer, corporate member or board member been the subject of a criminal investigation or enforcement action under the laws of the Commonwealth, or another state, the United States, or a military, territorial, or Indian tribal authority, including but not limited to action against any health care facility or facility for providing marijuana for medical purposes in which you either owned shares of stock or served as an executive, and which resulted in conviction, or guilty plea, or plea of nolo contendere, or admission of sufficient facts?

Yes No If yes, please explain:

Has any entity in which you have served as an executive, officer, corporate member or board member been the defendant or subject in any civil or administrative action under the laws of the Commonwealth, another state, the United States, or a military, territorial, or Indian tribal authority relating to your profession or occupation or fraudulent practices, including but not limited to fraudulent billing practices?

Yes No If yes, please explain:

1250 1250

10. Has any entity in which you have served as an executive, officer, corporate member or board member been determined by a court or governmental agency or tribunal to have engaged in any attempt to obtain a registration, license, or approval to operate in any state by fraud, misrepresentation, or the submission of false information?

Yes No If yes, please explain:

Signed under the pains and penalties of perjury, I agree and attest that all information included in this form is complete and accurate.

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Signature of the Individual	Date Signed