Applicant Corporation

SECTION D. EMPLOYMENT AND EDUCATION FORM

This Employment and Education form must be completed and signed by each of the following individuals:

The applicant’s Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, individual

responsible for marijuana for medical use cultivation operations, and individual responsible for the RMD

security plan and security operations. 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. Submit one Employment and Education form for each

of the above individuals when submitting a Management and Operations Profile to the Department of Public

Health.

Name of Individual

Residential Address of Individual

Title of Individual (at Applicant Corporation)

Name of Applicant Corporation

Highest Education Attained – Institution, Degree, and Year

Applicant Corporation

Past 10 Years of Employment by Employer, Title and Time Period. List chronologically, beginning with most recent employment. Add more forms if space is needed for additional employment history entries.

Employer	Title	Time Period

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

____________________________________________	Click here to enter a date.

Signature of the Individual Date Signed