Remittance Form

Registered Marijuana Dispensary Application Fee

Please remit this form with your bank/cashier’s check payable to

“The Commonwealth of Massachusetts” for proper posting of your payment

Date

Name of Applicant Corporation

MAILING ADDRESS OF APPLICANT CORPORATION

Address

City

State Zip Code

CONTACT PERSON

First Name

Last Name

Email Address

Phone Number

Amount Enclosed $_	Bank/Cashier’s Check Enclosed