MARIJUANA REGULATORY AGENCY│

Base Questions

These base questions are a required part of the prequalification application for sole proprietors and allsupplemental individuals and must be submitted with the prequalification application. Basequestions are not required for entity applications. Your response must be provided and will beconsidered with your other application documents.

The following forms are fillable PDFs and can be completed using standard PDF softwareapplications. Simply utilize the tab key or point and click with your mouse to navigate through thefillable fields. A separate PDF file with responses to the following questions must be returnedfor a sole proprietor and for all supplemental individuals. Questions regarding thesubmission of these forms may be directed to Medical Facilities Licensing at 517-284-8599.

Overview of the Following Forms (Table of Contents)▪ General Information

▪ Business Interests -- This form can be duplicated as many times as necessary to account forevery business interest. To duplicate this form and add another business interest, simply click the“Add Another Business” button found at the bottom of the form.

▪ Marijuana Associations -- This form can be duplicated as many times as necessary toaccount for every marijuana association. To duplicate this form and add another marijuanaassociation, simply click the “Add Another Facility” button found at the bottom of theform.

When you have completed all forms in their entirety, save your completed PDF. When naming yourcompleted PDF, please include the Applicant name as well as the Supplemental Applicant name (ifapplicable). For example, an appropriate PDF file name could be “Green Town LLC - John Smith –Base Questions”. Please email the completed PDF file to MRA-Applications@michigan.gov.

CUSTOMER DRIVEN. BUSINESS MINDED.

│ MARIJUNA REGULATORY AGENCY

General Information

Answers provided on the following forms pertain to:

Name of Sole Proprietor:

Name of Supplemental Individual:*A separate PDF file with responses must be returned for each supplemental individual.

Record ID:*Example of Record ID: "IRGA-18-555555"

CUSTOMER DRIVEN. BUSINESS MINDED.

│ MARIJUANA REGULATORY AGENCY

Business Interests**Provide a comprehensive overview of every business interest, regardless of whether the business is related to themarijuana industry. To add an additional business, select the "Add Another Business" button located at the bottomof this page; this will cause an additional Business Interests form to generate.

Name of business:

Assumed name or DBA (type N/A if not applicable):

Type of business entity (ex. sole proprietorship, LLC, corporation):

Type of business conducted. If a consulting business, describe the services provided and whether services areprovided by contract or other arrangement. If other arrangement, please describe the nature of arrangement:

What is the extent of your involvement in this business:

Is income received from this business? What is the nature and frequency of this income (ex. salary, draw)?

Is the business associated in any way to the applicant entity? Yes No

If Yes, please explain:

CUSTOMER DRIVEN. BUSINESS MINDED.

│ MARIJUANA REGULATORY AGENCY

Marijuana Associations**To add an additional facility, association, club, etc., select the "Add Another Facility" button located at the bottomof this page; this will cause an additional form to be generated.

Yes No *If Yes, please answer the below questions A through E

A) Name of facility, association, etc.:

B) Address of facility, association, etc.:

C) Names of other individuals associated with the facility, association, etc.:

D) What is the nature of your involvement?

E) Dates of operation/Dates of caregiver registration:

F) Indicate the number of patients in your care: 0 1 2 3 4

G) Indicate the amount of compensation received from your registered patients for medicalmarijuana and how the amount of compensation was determined:

CUSTOMER DRIVEN. BUSINESS MINDED.

Other than as a patient, have you ever been a registered medical marijuana caregiver or had any involvement in any capacity, with a current or previous facility, association, club, consulting service, or entity by any other description that provides or has provided marijuana?

5