ohio medical marijuana dispensary application ohio ......application id 966 demographic...
TRANSCRIPT
Ohio Medical Marijuana Dispensary Application
OHIO GROWN THERAPIES, LLC Application ID 966
Demographic Information(Business Contact)
A-1.1 Business Name, as it appears on the Applicant’s certificate of incorporation, charter, bylaws,partnership agreement or other legal business formation documents
A-1.2 Other trade names and DBA (doing business as) names
A-1.3 Business Street Address
A-1.4 City
A-1.5 State
A-1.6 Zip Code
A-1.7 Phone
A-1.8 Email
Ohio Grown Therapies, LLC
N/A
150 Commerce Blvd
Johnstown
OH
43031
6143544451
Demographic Information(Primary Contact/Registered Agent)
A-2.1 Please select: Primary Contact, or Registered Agent for this Application
A-2.2 First Name
A-2.3 Middle Name
A-2.4 Last Name
A-2.5 Street Address
A-2.6 City
A-2.7 State
A-2.8 Zip Code
A-2.9 Phone
A-2.10 Email
PRIMARY CONTACT
Andy
Paul
Joseph
150 Commerce Blvd.
Johnstown
OH
43031
6143544451
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Demographic Information(Applicant Organization and Tax Status)
A-3.1 Select One
A-3.1A If other, explain
A-3.2 State of Incorporation or Registration
A-3.3 Date of Formation
A-3.4 Business Name on Formation Documents
A-3.5 Federal Employer ID number
A-3.6 Ohio Unemployment Compensation Account Number
A-3.7 Ohio Department of Taxation Number (if Applicant is currently doing business in Ohio)
A-3.8 Ohio Workers’ Compensation Policy Number (if Applicant is currently doing business in Ohio)
A-3.9 The Applicant attests that workers’ compensation insurance will be obtained by the time theState of Ohio Board of Pharmacy determines the Applicant to be operational under the Act andregulations.
A-3.10 Has the Applicant operated and conducted business in any jurisdiction other than Ohio in thepast three years? If you select "Yes", answer question A-3.10.1 below.
A-3.10.1 If "Yes" to question A-3.10, for each instance relevant to question A-3.10, provide thefollowing:
Legal Business NameBusiness AddressFederal Employee ID Number
Limited Liability Company
N/A
OH
10/17/2016
Ohio Grown Therapies, LLC
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
YES
NO
No response provided by applicant
Demographic Information(Economically Disadvantaged Business)
A-4.1 The Applicant attests that at least fifty-one percent of the business, including corporate stock if acorporation, is owned by persons who belong to one or more of the groups set forth in this division, andthat those owners have control over the management and day-to-day operations of the business andan interest in the capital, assets, and profits and losses of the business proportionate to theirpercentage of ownership. ORC 3796.10 NO
Demographic Information(District Information )
A-5.1 Please select to indicate the medical marijuana dispensary Ohio district for which you areapplying for a dispensary license
A-5.2 Please select to indicate the medical marijuana dispensary Ohio county for which you areapplying for a dispensary license
SOUTHEAST-3
Franklin
Demographic Information(Prospective Associated Key Employees Details)
Item 1 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Scott
Thomas
Miglin
N/A
Pharmacist
Director of Dispensaries
$130,000
N/A
N/A
N/A
N/A
OTHER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
85 Woodlake Trail
Mount Vernon
OH
43050
7403985858
No response provided by applicant
18 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 2 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Michael
Dane
Backes
N/A
Research/Writer
Science and Medical Advisory Board Member
$6000
N/A
N/A
N/A
N/A
OTHER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
7213 Santa Monica Blvd
Los Angeles
CA
90046
4246539992
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 3 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Richard
Tredwell
Baxter
N/A
Consultant
Owner
N/A
Indirectly (through another LLC) own 387,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 3.87%
N/A
OWNER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
4975 N. La Lomitz
Tucsan
AZ
85718
5205770700
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 4 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Justin
Thomas
Fischedick
N/A
Scientist
Science and Medical Advisory Board
$6000
N/A
N/A
N/A
N/A
OTHER
N/A
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-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
416 49th Street
Oakland
CA
94609
2063590654
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 5 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Allen
R.
Grogan
N/A
Attorney
Chief Legal Counsel
N/A
Indirectly (through another LLC) own 8.5% of applicant
Indirect ownership of LLC Founder Units
Indirect ownership of 8.5%
N/A
OWNER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
8637 Allenwood Road
Los Angeles
CA
90046
3236540327
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 6 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Jeffrey
Bryant
McElroy
N/A
Consultant in Agriculture
Science and Medical Advisory Board Member
$6,000
N/A
N/A
N/A
N/A
OTHER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
51 Farms Edge Road
North Yarmouth
ME
04097
2078473416
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 7 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
James
Benjamin
Peake
N/A
Physician
Science and Medical Advisory Board Member
$6000
N/A
N/A
N/A
N/A
OTHER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
7310 Admirals Park Drive
Jonestown
TX
78645
2023862135
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 8 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Andrew
Thomas
Weil
N/A
Physician/Author
Science and Medical Advisory Board Member
N/A
Indirectly (through another LLC) own 387,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 3.87%
N/A
OWNER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
7650 E. Broadway Blvd, STE 310
Tuscon
AZ
85710
5206477865
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 9 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
David
Clayton
Cole
N/A
Executive
Chairman of Board of Managers
N/A
Indirectly (through another LLC) own 799,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 7.99%
N/A
OWNER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
13500 Haleakala Hwy
Kula
HI
96790
7033093000
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 10 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Andrew
Paul
Joseph
N/A
President/Owner
CEO
$150,000
Indirectly (through another LLC) own 2,737,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 27.37%
N/A
OWNER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
146 Liberty Ridge Ct
Johnstown
OH
43031
6143544451
Non-Minority
46 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 11 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Kristen
Marie Merlo
Joseph
N/A
Director of Finance
Chief Quality Assurance Office
$150,000
Indirectly (through another LLC) own 2,737,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 27.37%
N/A
OWNER
N/A
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A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
146 Liberty Ridge Ct
Johnstown
OH
43031
6142868181
Non-Minority
29 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 12 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Margaret
No response provided by applicant
Cole
No response provided by applicant
Investor
Owner
N/A
Indirectly (through another LLC) own 555,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 5.55%
N/A
OWNER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
13500 Haleakala Highway
Kula
HI
96790
8082140190
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 13 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Miles
Richard
Gilburne
N/A
Venture Capital Investor
Chair of Investment Committee/Board Member
$0.00
Indirectly (through another LLC) own 774,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 7.74%
N/A
OWNER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
5060 E Sky Desert Lane
Paradise Valley
AZ
85253
2023602053
Non-Minority
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 14 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Nina
Beth
Zolt
N/A
Executive
Owner
N/A
Indirectly (through another LLC) own 774,000 Founders Units
Indirect ownership of LLC Founders Units
Indirect ownership of 7.74%
N/A
OWNER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
5060 E Sky Desert Lane
Paradise Valley
AZ
85253
2023294026
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 This response has been entirely redacted
Demographic Information(Prospective Associated Key Employees Details)
Item 15 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Donald
Ira
Abrams
N/A
Physician/Professor
Chief Medical Officer
$6,000.00
N/A
N/A
N/A
N/A
OTHER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
3927 26th Street
San Francisco
CA
94131
4152989554
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 16 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Pat
Dominic
Catanzarite
N/A
Financial Consultant
Chief Financial Officer
150,000
N/A
N/A
N/A
N/A
OTHER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
756 Gatehouse Ln
Columbus
OH
43235
6143147940
No response provided by applicant
50 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 17 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Jeremy
Craig
Sexton
N/A
Director of Engineering
Chief Compliance Officer
$130,000
N/A
N/A
N/A
N/A
OTHER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
5534 Breshly Way
Westerville
OH
43081
9372434776
Non-Minority
6 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 18 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Jeremy
Monroe
Didion
N/A
Director of Production
COO
$130,000
N/A
N/A
N/A
N/A
OTHER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
398 N Old State Rd
Delaware
OH
43015
4192178763
Non-Minority
44 years
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Demographic Information(Prospective Associated Key Employees Details)
Item 19 of 19
A-6.1 First Name
A-6.2 Middle Name
A-6.3 Last Name
A-6.4 Suffix
A-6.5 Occupation
A-6.6 Title in the Applicant’s business
A-6.7 Applicant's business related compensation
A-6.8 Number of shares owned
A-6.9 Types of shares owned
A-6.10 Percent interest in Applicant's business
A-6.11 Voting percentage
A-6.12 Proposed Role
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Brian
Keith
Becker
N/A
Physician/Consultant
Institutional Review Officer
$6,000
N/A
N/A
N/A
N/A
OTHER
N/A
--
-
A-6.14 Date of birth
A-6.15 Social Security Number (use "N/A" if unavailable)
A-6.16 Street Address
A-6.17 City
A-6.18 State
A-6.19 Zip Code
A-6.20 Phone
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide thelength of time for which Ohio residency has been established:
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity:Unexpired, valid state-issued driver's license.Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or theequivalent from another state.Unexpired, valid United States passport.
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownershipinterest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the TaxAuthorization Form. The State Board of Pharmacy may, in its discretion, require an owner or personwho exercises substantial control over a proposed dispensary, but who has less than a ten percent
This response has been entirely redacted
This response has been entirely redacted
5720 E. North Wilshire Dr.
Ticson
AZ
85711
5207229900
No response provided by applicant
N/A
This response has been entirely redacted
ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02 No response provided by applicant
Compliance(Compliance with Applicable Laws and Regulations)
B-1.1 By selecting “Yes”, the Applicant, as well as all individually identified Prospective Associated KeyEmployees listed in this provisional license application, agree to comply with all applicable Ohio lawsand regulations relating to the operation of a medical marijuana dispensary.
B-1.2 By selecting “Yes”, the Applicant understands and attests that it must establish and maintain anescrow account or surety bond in the amount of $50,000 as a condition precedent to receiving amedical marijuana certificate of operation. OAC 3796:6-2-11
YES
YES
Compliance(Civil and Administrative Action)
B-2.1 Has the Applicant been the subject of an action resulting in sanctions, disciplinary actions or civilmonetary penalties or fines being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-2.2 Has the Applicant been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-2.3 Has criminal, civil, or administrative action been taken against the Applicant for obtaining aregistration, license, provisional license or other authorization to operate as a cultivator, processor, ordispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission offalse information?
B-2.4 Has criminal, civil or administrative action been taken against the Applicant under the laws ofOhio or any other state, the United States or a military, territorial or tribal authority, relating to any ofthe Applicant's Prospective Associated Key Employees' profession or occupation?
B-2.4.1 If "Yes" to any question in B-2, provide the following: Respondent / Defendant, Name of Caseand Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Nameand Address of the Administrative Agency Involved, and the Jurisdictional Court (Specify Federal,State and/or Local Jurisdictions)
NO
NO
NO
NO
No response provided by applicant
Compliance(Prospective Associated Key Employee Compliance)
Item 1 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Scott
Thomas
Miglin
OTHER
Director of Dispensaries
Oversees dispensary operations in conjunction with dispensary Designated Representative
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 2 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Michael
Dane
Backes
OFFICER
Science and Medical Advisory Board Member
Directs education, training, and curriculum development for our Dispensary.
YES
Cornerstone Research Collective 2551 Colorado Blvd. Los Angeles, CA 90041
YES
Cornerstone Research Collective 2551 Colorado Blvd. Los Angeles, CA 90041
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 3 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
Richard
Tredwell
Baxter
PERSON WITH FINANCIAL INTEREST
Owner
Owner
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 4 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Justin
T.
Fischedick
OTHER
Science and Medical Advisory Board Member
Science and Medical Advisory Board Member
YES
Excelsior Analytical Laboratory, 30099 Ahern Ave., Union City, CA 94587
YES
Excelsior Analytical Laboratory, 30099 Ahern Ave., Union City, CA 94587
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 5 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
Allen
No response provided by applicant
Grogan
OWNER
Chief Legal Counsel
Provide legal advice and services
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 6 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Jeffrey
Bryant
McElroy
OTHER
Science and Medical Advisory Board Member
Directs education, training, and curriculum development for our Dispensary.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 7 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
James
Benjamin
Peake
OTHER
Medical Advisor
Directs education, training, and curriculum development for our Dispensary.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 8 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
Andrew
Thomas
Weil
OTHER
Science and Medical Advisory Board Member
Directs education, training, and curriculum development for our Dispensary.
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 9 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
David
No response provided by applicant
Cole
OWNER
No response provided by applicant
Chairman
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES
As a board member and executive of several public companies, Mr. Cole was a named
defendant, along with other board members and executives, in class action shareholder
lawsuits routinely filed by plaintiff class action lawyers upon the sale or merger of those
companies or precipitous drop in the share price of those companies after
announcement of negative news. Plaintiffs alleged breaches of federal and state
securities laws and fiduciary duties in these lawsuits. All of these law suits were
defended by insurance companies. They were either settled or dismissed without
admission of guilt or Mr. Cole was removed as a party. The primary named defendant,
docket number, date of filing and jurisdiction for these shareholder class action suits are
as follows: (i) Solazyme; 4:15-CV-03880; 2015; U.S. District Court Northern District of
California; (ii) Solazyme; 4:15-CV-02938; 2015; U.S. District Court Northern District of
California; and (iii) America Online; 97-CV-00264;1997; U.S. District Court Eastern
District of Virginia.
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 10 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Andrew
Paul
Joseph
OWNER
Chief Executive Officer
Directs planning, implementation and integration of the company’s operations
YES
Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 11 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Kristen
No response provided by applicant
Joseph
OWNER
Chief Quality Assurance Officer
Oversees the safety and quality assurance of all products and services
YES
Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
any other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 12 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
Margaret
Mary Butler
Cole
OWNER
No response provided by applicant
Owner
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 13 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
Miles
Richard
Gilburne
OWNER
Board Member
Leads OGT's capital formation and intellectual property initiatives
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES
As a board member and executive of several public companies, Mr. Gilburne was a
named defendant, along with other board members and executives, in class action
shareholder lawsuits routinely filed by plaintiff class action lawyers upon the sale or
merger of those companies or precipitous drop in the share price of those companies
after announcement of negative news. Plaintiffs alleged breaches of federal and state
securities laws and fiduciary duties in these lawsuits. All of these lawsuits were
defended by insurance companies and settled or dismissed without admission of guilt.
The primary named defendant, docket number, date of filing and jurisdiction for these
shareholder class action suits are as follows: (i) SRA International; Case 1:11-CV-0047;
2011; U.S. District Court Eastern District of Virginia.; (ii) AOLTimeWarner; MDL Docket
No. 1500,02, Civ. 5575; 2002; U.S. District Court Southern District of New York; and (iii)
America Online; 1:97-CV-00264;1997; U.S. District Court Eastern District of Virginia.
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 14 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or the
Nina
Beth
Zolt
OWNER
N/A
Owner
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
YES
Maui Wellness Group, P.O. Box 672, Kula, HI, 96790-0672Ohio Grown Therapies, LLC 150 Commerce Dr. Johnstown, OH 43031 (Applicant for OH cultivationlicense)
equivalent thereof in another jurisdiction.
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
surrender, suspension, revocation, or probation of the individual's license or registration?
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
NO
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 15 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Donald
Ira
Abrams
OTHER
Science and Medical Advisory Board Member
Directs education, training, and curriculum development for our Dispensary.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 16 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Pat
Dominic
Catanzarite
OTHER
Chief Financial Officer
Directs financial planning, record keeping, reporting and risk management
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 17 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Jeremy
Craig
Sexton
OTHER
Chief Compliance Officer
Manages regulatory compliance and reporting programs
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 18 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Jeremy
Monroe
Didion
OTHER
Chief Operating Officer
Manages day-to-day manufacturing and production operations
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
Compliance(Prospective Associated Key Employee Compliance)
Item 19 of 19
B-3.1 First Name
B-3.2 Middle Name
B-3.3 Last Name
B-3.4 Proposed Role
B-3.5 Position/Title
B-3.6 Brief description of role
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member ofanother medical marijuana entity in Ohio or the United States?
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership orfinancial interest of another medical marijuana entity in Ohio or the United States?
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense?Include instances in which a court granted intervention in lieu of treatment (also known as treatment inlieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless ofwhether the case has been sealed, as described in section 2953.32 of the Revised Code, or theequivalent thereof in another jurisdiction.
Brian
Keith
Becker
OTHER
Science and Medical Advisory Board Member
Directs education, training, and curriculum development for our Dispensary.
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number,Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court(Specify Federal, State and/or Local Jurisdictions)
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offenseunder state or federal law?
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony ormisdemeanor) involving an act of moral turpitude?
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Natureof Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (SpecifyFederal, State and/or Local Jurisdictions)
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any otherlicensing body.
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, LicenseNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration orappropriate issuing body of any state or jurisdiction, or is such action pending?
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the DrugEnforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in thesurrender, suspension, revocation, or probation of the individual's license or registration?
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug EnforcementAdministration or appropriate issuing body of any state jurisdiction that was based in whole or in part,on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing,compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescriptiondrug), or is any such action pending?
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant FingerprintDatabase (Rapback) should the Applicant be awarded a provisional license.
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions orcivil monetary penalties being imposed relating to a registration, license, provisional license or anyother authorization to cultivate, process, or dispense medical marijuana in any state?
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration,license, provisional license or authorization to cultivate, process, or dispense medical marijuana in anystate?
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or otherauthorization to operate as a cultivator, processor, or dispensary of medical marijuana in anyjurisdiction by fraud, misrepresentation, or the submission of false information?
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio orany other state, the United States or a military, territorial or tribal authority, relating to the individual'sprofession or occupation?
No response provided by applicant
NO
No response provided by applicant
YES
NO
No response provided by applicant
NO
No response provided by applicant
NO
No response provided by applicant
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and DocketNumber, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Addressof the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or LocalJurisdictions)
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificateto recommend medical marijuana or who has applied for a certificate to recommend medical marijuanaunder section 4731.30 of the Revised Code.
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest,or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
NO
No response provided by applicant
YES
YES
--
-
Business Plan(Property Title, Lease, or Option to Acquire Property Location)
C-1.1 Attach one of the following: Evidence of the Applicant’s clear legal title to or option to purchase the proposed site and facility.A fully-executed copy of the Applicant’s unexpired lease for the proposed site and facility and awritten statement from the property owner that the Applicant may operate a medical marijuanaorganization on the proposed site for, at a minimum, the term of the initial provisional license.Other evidence that shows that the Applicant has a location to operate its medical marijuanaorganization.
Uploaded Document Name: C-1.1_Location to operate3.pdfNOTE: This applicant uploaded document is the next 14 page(s) of this document.
C-1.2 Business Name, as it appears on the Applicant’s certificate of incorporation, charter, bylaws,partnership agreement or other official documents.
C-1.3 Trade names and DBA (doing business as) names
C-1.4 Business Address
C-1.5 City
C-1.6 State
C-1.7 Zip Code
C-1.8 Phone
C-1.9 Email
Ohio Grown Therapies, LLC
Ohio Grown Therapies
4491 Kenny Rd
Columbus
OH
43220
6143544451
-
-
-
Business Plan(Site and Facility Plan)
C-2.1 Applicants must show that they can expeditiously use a site and facility to meet the activitiesdescribed in the provisional license by attaching one of the following:
If the facility is in existence at the time that the provisional license application is submitted, submitplans and specifications drawn to scale for the interior of the facility.If the facility is in existence at the time that the provisional license application is submitted, and theApplicant plans to make alterations to the facility, submit renovation plans and specifications for theinterior and exterior of the facility.If the facility does not exist at the time that the provisional license application is submitted, submit aplot plan that shows the proposed location of the facility and an architectural drawing of the facility,including a detailed drawing, to scale, of the interior of the facility.
Uploaded Document Name: C-2.1_Facility plans3.pdfNOTE: This applicant uploaded document is the next 2 page(s) of this document.
C-2.2 The Applicant also must submit evidence that it is in compliance with any local ordinances, rules,or regulations adopted by the locality in which the Applicant's property is located, which are in effect atthe time of the application. Include copies of any required local registration, license or permit. If norelevant zoning restrictions have been enacted, provide a professionally prepared survey whichdemonstrates that the Applicant is not in violation of restrictions pertaining to prohibited facilities and isnot located within 500 feet of a community addiction services provider as defined under section5119.01 of the Revised Code. OAC 3796:5-5-01 Uploaded Document Name: C-2.2_Zoning form3.pdfNOTE: This applicant uploaded document is the next 2 page(s) of this document.
C-2.3 Provide a location map of the area surrounding the proposed facility that establishes the facilityis at least 500 feet from a prohibited facility or a community addiction services provider as definedunder section 5119.01 of the Revised Code. In establishing the distance between a proposeddispensary and such a facility, the distance shall be measured linearly and shall be the shortestdistance between the closest point of the property lines of the proposed dispensary and the prohibitedfacility or community addiction services provider. The map must be clearly legible and labeled and maybe divided into 8.5*11 inch sections. OAC 3796:5-5-01 Uploaded Document Name: C-2.3_Location Area Map3.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
1.2.3.4.5.6.
Business Plan(Business Startup Plan)
C-3.1 A business startup plan is required for all dispensary provisional license applications. Thebusiness startup plan must provide a comprehensive set of activities necessary for the startup of thefacility within six months of receiving a provisional license. Provide a timeline describing the process,methods, or steps used to execute a compliant business startup plan that includes, at a minimum:
Security and surveillanceEmployee qualifications and trainingStorage of medical marijuana productsInventory managementRecord-keepingPrevention of medical marijuana diversion
C-3.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in C-3.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: C-3.1.1_Business startup plan3.pdfNOTE: This applicant uploaded document is the next 3 page(s) of this document.
1.2.3.4.5.6.
C-3.2 The Business Startup Plan also must describe how the Applicant’s proposed businessoperations will comply with statutory and regulatory requirements (as described in Chapter 3796 of theRevised Code and division 3796:6 of the Administrative Code) necessary for the startup and continuedoperation of the facility including, but not limited to:
Security and surveillanceEmployee qualifications and trainingStorage of medical marijuana productsInventory managementRecord-keepingPrevention of medical marijuana diversion
Business Plan(Description of Employee Duties and Roles)
C-4.1 Please provide a description of the duties, responsibilities, and roles of each ProspectiveAssociated Key Employee. Please attach a Table of Organization and Control for the business. Include all individuals listed in question A-6. TRADE SECRET
The following is a list of all prospective associated key employees (PAKEs) of the applicant OhioGrown Therapies (OGT or Company), organized by roles with brief description of duties andresponsibilities. Some PAKEs are listed more than once due to fulfilling multiple roles. Tables ofOrganization and Table of Organization: Qualifications of PAKEs are attached.
BOARD OF MANAGERS DUTIES & RESPONSIBILITESAs the ultimate governing authority, the Board of Managers (“OGT Board”) sets strategy, hiresexecutives, evaluates Company performance, assesses risk and ensures compliance with allapplicable laws and regulations.
The OGT Board is comprised of David Cole, Andy Joseph, Kristen Joseph and Miles Gilburne, provenbusiness leaders with extensive startup experience, including expertise in the medical cannabisindustry.
David Cole: Chairman. In consultation with the Company’s CEO, the Chairman sets OGT’s Boardagenda, conducts periodic meetings and acts as liaison between management and the OGT Board. Heis aware of the key activities of the Company and its management and guides OGT Boarddeliberations on material business and compliance matters. He is Co-founder/General Manager ofMaui Grown Therapies, a licensed medical cannabis cultivation, manufacturing and dispensingcompany in Hawaii. He has over 35 years’ experience assembling, motivating and serving executiveteams as a CEO and director for numerous public and private companies.
Andy Joseph: OGT Board Member and Chief Executive Officer. As CEO he directs the planning,implementation and integration of operations in accordance with the strategies and policies set by theOGT Board. He is the founder/CEO of Apeks Supercritical, a leading supplier of processing equipmentto the cannabis industry for 15 years.
Kristen Joseph: OGT Board Member and Chief Quality Assurance Officer, responsible for all safety,quality assurance and compliance matters. She is Director of Finance at Apeks Supercritical where shealso serves as the Safety and Quality Assurance Manager.
Miles Gilburne: OGT Board Member. Leads OGT’s capital formation and intellectual propertyinitiatives. He is a venture capitalist, corporate executive and attorney with extensive governanceexperience on public and private boards.
SCIENCE AND MEDICAL ADVISORY BOARD (SMA) ROLES & RESPONSIBILITESThe SMA directs the Company’s education, training, and product selections based on current peer-reviewed research on cannabis formulations and clinical outcomes.
The SMA is comprised of physicians, scientists and academic authorities with expertise in clinicalmedicine, cannabis research, botany, biochemistry, integrative medicine, health care policy andregulatory compliance. Members are:
Andrew Weil, M.D., Chief Science Officer. As chairman, Dr. Weil convenes the quarterly meetings ofthe SMA to review the latest developments in medical cannabis research, product development andpatient education. A nationally respected authority on integrative therapies in patient care and aninternationally recognized expert on medicinal plants and integrative medicine and an author ofnumerous scientific articles and books on psychoactive substances.
Donald Abrams, M.D., Chief Medical Officer. Designs research instruments, evaluates patient data andsets OGT’s research agenda. A 20-year researcher on the effects of cannabis on human health. Hiscurrent research includes assessing the potential for cannabis-based formulations to potentiate lowdose opioid treatment for chronic pain.
Michael Backes, Curriculum and Training Advisor. Authors OGT’s training materials and instructionalprograms with the assistance of the Chief Pharmacist/Director of Dispensaries. He personally leads theannual OGT Academy instructional courses for employees.
James B. Peake, M.D., Lt. Gen. (Ret), Medical Advisor. Tracks research on the potential benefits ofmedical cannabis for veterans suffering from PTSD and other service-related disabilities. Former U.S.Secretary of Veterans Affairs and U.S. Army Surgeon General.
Brian Becker, M.D., Institutional Review Officer. Advises the Chief Pharmacist/Director of Dispensarieson regulatory compliance matters. As a consultant in integrative medicine and related productdevelopment, he served as an FDA compliance officer for 7 years. Currently the Medical Director fortwo medical cannabis dispensaries licensed in the state of Arizona.
Jeffrey McElroy, Ph.D., Science Advisor. As a botanist and plant breeder, he provides insights on thecharacteristics of cannabis cultivars. Over 40 years of experience in commercial agriculture includingmedical cannabis production operations in Maine and Hawaii, where he is Chief Cultivation Advisor forMaui Grown Therapies.
Justin Fischedick, Ph.D., Science Advisor. As an analytical and process chemist, he advises thecompany on advances in cannabis testing and quality assurance methods. Author or co-authorscientific articles on cannabis, cannabinoids and terpenoids published in top scientific and medicaljournals.
EXECUTIVE MANAGEMENT TEAM ROLES & DUTIESThe Executive Management Team (EMT) is charged with implementing the strategy, policies andvalues as set by the OGT Board.
The EMT has a proven history of high performance teamwork as the leadership team at ApeksSupercritical, an Ohio-based manufacturer of botanical oil extraction equipment for the cannabisindustry. Each member of the EMT has 15 to 25 years of business experience. Collectively, theirbackgrounds, roles and responsibilities include: operations, compliance, quality control, security,finance, marketing, project management, human relations, sales and customer service.
Andy Joseph, Chief Executive Officer. Unifies the EMT in planning, implementing and integrating thestrategies and policies established by the OGT Board. Provides leadership in all facets of internal andexternal activities, including setting standards for operational excellence, meeting and exceedingpatient expectations, managing external messaging, and setting high standards of conduct for the Ohiomedical cannabis industry.
Allen Grogan, Chief Legal Counsel. Monitors and interprets existing and emerging regulations and
C-4.2 Please attach a Table of Organization and Control for the business. Include all individuals listedin question A-6.
works with the Chief Compliance Officer to produce policies and procedures to ensure 100%compliance with applicable laws.
Jeremy Didion, Chief Operating Officer. Responsible for all activities influencing costs in theCompany’s P&L.
Kristen Joseph, Chief Quality Assurance Officer. Responsible for product integrity and supply chainmanagement. Directs all human resources programs, including attracting and retaining a diverse,customer service minded work force.
Pat Catanzarite, Chief Financial Officer. Directs financial planning, controls, record keeping, reportingand risk management. Interfaces with the Company’s investors, financial institutions and externalauditors.
Jeremy Sexton, Chief Compliance Officer. Works in concert with the Chief Legal Counsel to interpretOMMCP regulations and implement policies and procedures to achieve the Company’s goal of 100%compliance. Responsible for the safety/security of employees, patients and community.
Scott Miglin, R.Ph., Director of Dispensaries. Oversees all operational aspects of dispensaries andworks in conjunction with Chief Compliance Officer to direct all matters of compliance at theDispensary. Reviews and approves all employee and patient education materials prior toimplementation at the dispensaries. (3796:6-3-19(G)(O))
OWNERSBelow are those with an ownership percentage in the Dispensary. In any case where the principalplace of business changes, it is the responsibility of ownership to notify the Board of the change((3796:6-3-02(G)).
Andy Joseph, 27.37%Kristen Joseph, 27.37%David Cole*, 15.73%Miles Gilburne**, 15.48%Allen Grogan, 8.50%Andrew Weil, M.D., 3.87%Richard Baxter, 3.87%
*Held in common with Margaret Cole, spouse** Held in common with Nina Zolt, spouse
Uploaded Document Name: C4.2_Table of organization.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
Business Plan(Capital Requirements)
Item 1 of 1
C-5.1 Type of Capital
C-5.2 Source of Capital
C-5.3 Name and Address of financial institution
C-5.4 Account Number
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for thefirst year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3).The total amount of liquid assets must be no less than $250,000. Provide unredacted documentationfrom the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution tosupport the capital requirements. (ORC 3796:6-2-02)
Cash and equivalents, municipal bonds
One of our owners, Miles R. Gilburne
This response has been entirely redacted
This response has been entirely redacted
This response has been entirely redacted
Uploaded Document Name: C-5.5.1_Capital Requirements REDACTED.pdfNOTE: This applicant uploaded document is the next 14 page(s) of this document.
PLEDGE OF LIQUID ASSETS SUFFICIENT TO COVER COSTS AND EXPENSES OF THE FIRST YEAR OF
OPERATION
Attached is a financial statement from [Name Redacted] dated October 31, 2017 showing liquid assets
totaling $7,132,348 that are unencumbered and capable of being converted within 30 days after a
request to liquidate such assets. This exceeds by a substantial amount the total liquid assets needed to
cover all expenses and costs of the first year of operation for all five dispensary licenses for which the
Applicant is applying, which total in the aggregate (for all five dispensary locations) $3,839,785,
approximately 54% of the amount of liquid assets reflected in the attached financial statement.
The undersigned hereby unconditionally pledges to make the funds reflected in the attached financial
statement available to the Applicant as needed to cover expenses and costs for the first year of
operation of any and all of the five (5) dispensaries for which Applicant is submitting license
applications. The undersigned is identified as a Prospective Associated Key Employee (PAKE) in the
Applicant’s dispensary applications.
/Signature redacted/
[Name of Signatory Redacted]
Applicant: [Name Redacted]
Dated: November 15, 2017
Estimated costs and expenses required -- start-up + 12 months operating
Location 1 $616,476
Location 2 $959,627
Location 3 $979,977
Location 4 $643,977
Location 5 $639,727
Total estimated costs and expenses 5 dispensaries $3,839,785
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11
Business Plan(Business History and Experience)
Item 1 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Kristen
Marie Merlo
Joseph
Officer
Apeks LLC dba Apeks Supercritical
150 Commerce Blvd, Johnstown, OH 43031
YES
11/2013 - Present
Business Plan(Business History and Experience)
Item 2 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Miles
Richard
Gilburne
Owner, Officer
Cricket Media
12020 Sunrise Valley Dr, Suite #100, Reston, Virginia, 20191
YES
2005 - Present
Business Plan(Business History and Experience)
Item 3 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Miles
Richard
Gilburne
Owner
Maui Grown Therapies
PO Box 672, Kula, HI 96790
NO
2016 - Present
Business Plan(Business History and Experience)
Item 4 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Margaret
Mary Butler
Cole
Person with financial interest
Pan Pacific Ventures
PO Box 672, Kula, HI 96790
NO
1987-current
Business Plan(Business History and Experience)
Item 5 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Miles
Richard
Gilburne
Owner, Officer
ZG Ventures LLC
12020 Sunrise Valley Dr, Suite #100, Reston, Virginia, 20191
YES
2000 - Present
Business Plan(Business History and Experience)
Item 6 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Kristen
Marie Merlo
Joseph
Support Employee
EWI
1250 Arthur E Adams Blvd, Columbus, OH 43221
NO
May 2001 - November 2013
Business Plan(Business History and Experience)
Item 7 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Andrew
Paul
Joseph
Owner
Apeks LLC dba Apeks Supercritical
150 Commerce Blvd, Johnstown, OH 43031
YES
02/2002 - Present
Business Plan(Business History and Experience)
Item 8 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Nina
Beth
Zolt
Managing Member
ZG Ventures, LLC
12020 Sunrise Valley Dr., Suite 100, Reston, VA 20191
YES
December 2001-Present
Business Plan(Business History and Experience)
Item 9 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
David
Clayton
Cole
Officer, Director, Shareholder
Solazyme, Inc.
225 Gateway Blvd, S. San Francisco, CA 94080
YES
February 2010 - October 2014
Business Plan(Business History and Experience)
Item 10 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
David
Clayton
Cole
Owner, Officer, Administrative and Managing Member
Maui Wellness Group, LLC DBA Maui Grown Therapies
PO Box 672, Kula, HI 96790
YES
October 2015 to present
Business Plan(Business History and Experience)
Item 11 of 11
C-6.1 First Name
C-6.2 Middle Name
C-6.3 Last Name
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, PersonExercising Substantial Control, Support Employee)
C-6.5 Business Name
C-6.6 Business Address
C-6.7 Position of management or ownership of a controlling interest
C-6.8 Dates
Nina
Beth
Zolt
Owner, Officer
Cricket Media
12020 Sunrise Valley Dr, Suite #100, Reston, Virginia, 20191
YES
2005 - Present
Business Plan(Business History and Experience Narrative)
C-6.9 Provide a narrative description not to exceed 1500 words demonstrating any previousexperience at operating other businesses or non-profit organizations and any demonstrated knowledgeor expertise with regard to the medical use of marijuana to treat qualifying conditions (for allProspective Associated Key Employees with an ownership interest of ten percent or more in theprospective dispensary). Include the number of years of experience, the type of business, and anyadministrative discipline history associated with each business. TRADE SECRET
OHIO GROWN THERAPIES (OGT) OVERVIEW/EXECUTIVE SUMMARYOGT brings an experienced, interdisciplinary team to the creation, launch and operation of a cannabisdispensary. We are physicians, botanists, plant geneticists, cultivators, quality control and securityadvisors, educators, supply chain managers, financial managers and general business executives. Wehave worked in multiple industries at all stages of business development from start-ups to Fortune 500companies with proven track records of regulatory compliance in complex, highly regulated industries,as demonstrated by the absence of any administrative disciplinary action throughout our long careers.
OGT operations are run under the guidance of our Board of Managers by a cohesive EXECUTIVEMANAGEMENT TEAM, five of whom have worked together at Apeks Supercritical, a manufacturer ofCO2 botanical extraction equipment in Johnstown, OH, growing it from a startup into an industryleading, multi-million-dollar company with national reach. Each Executive Team Member (PAKE) has15 to 25 years of experience in one or more of the following: operations, regulatory compliance, qualitycontrol, security, sales/service, project management, marketing, human relations and finance.
Our SCIENCE AND MEDICAL ADVISORY BOARD (SMA) directs and supports Dispensary stafftraining, staff and patient education and patient care. These physicians and scientists are deeplyinvolved in the rapidly evolving study of cannabis and its clinical application in treating qualifyingconditions under the OMMCP. The SMA monitors, evaluates and prioritizes current research to provideactionable recommendations for the safety and efficacy of cannabis-based therapies offered at ourDispensary.
Members of our Board of Managers, Executive Management Team and SMA, along with their relevantexperience, include:
DAVID COLE: CHAIRMAN OF BOARD OF MANAGERSDavid Cole has 35-plus years of executive experience in multiple industries, including industrialbiotechnology, software, online services, renewable energy, retailing, organic foods, resortdevelopment and medical cannabis products.Mr. Cole is Co-founder and General Manager of Maui Grown Therapies (MGT). MGT earned the firstlicense in Hawaii to cultivate, manufacture, transport and dispense medical cannabis products. AtMGT, he structured and led over $10 million in financing and directed the design, construction andcommissioning of all cultivation, manufacturing and dispensary facilities.Mr. Cole has led or been part of the executive team or board of numerous public and privatecompanies, investment funds and non-profit organizations over the past three decades, including:America Online (online services); Maui Land & Pineapple (agriculture and real estate); StarbucksHawaii (retailing); Cole Gilburne Fund (venture capital); Ziff Communications (publishing); Ashton Tate(software); Solazyme (biotechnology); American Farmland Trust, The Nature Conservancy and WorldWildlife Fund (conservation); and PBS and Sesame Workshop (media).
MILES GILBURNE: BOARD OF MANAGERSMiles Gilburne has been active for nearly 30 years as a venture capitalist, corporate executive, boardmember of public and private companies, and technology lawyer. He is currently managing member ofZG Ventures, an early-stage venture capital firm focused on education media, information technology,pharmaceutical development and bioinformatics.Mr. Gilburne has led or been a member of the senior executive team, board or partnership ofnumerous public and private companies, investment funds, law firms and non-profit organizations,including: Maui Grown Therapies (medical cannabis); Pharmacyclics (drug development); Brainscope(medical devices); NIH Foundation (medical research); Time Warner (media); America Online (onlineservices); National Geographic Ventures (media); Cricket Media (education); SRA (IT services); ColeGilburne Fund (venture capital); and Weil Gotshal (law).
ANDY JOSEPH: BOARD OF MANAGERS & CHIEF EXECUTIVE OFFICERAndy Joseph is founder and president of Apeks Supercritical, a manufacturer of supercritical extractionequipment used to extract oils from cannabis to create concentrates for medicinal use. Apeks hassupplied over 500 systems to licensed cannabis customers in every regulated state in the U.S.Mr. Joseph has more than 15 years of experience in executive leadership at Apeks after working forseveral years in engineering and operations management for Edison Welding Institute (EWI).In 2016, he was named a regional winner of the EY (Ernst & Young) Entrepreneur of the Year Awardand Columbus Business First BizTech, Executive of the Year. In addition, Apeks won an EdisonAward, selected from a competitive international field for providing exemplary product and servicesA native Ohioan, Mr. Joseph is a two-time Navy Achievement Medal recipient.
KRISTEN JOSEPH: BOARD OF MANAGERS & CHIEF QUALITY ASSURANCE OFFICEROhio native Kristen Joseph is Director of Finance at Apeks Supercritical. In addition to handling allfinancial matters, she utilizes her project management skills and 16 years’ engineering experience inher roles as Safety Officer and Quality Assurance Manager -- both of which will be critically importantto ensure the production of safe, quality-assured cannabis therapies.
SCOTT MIGLIN, RPH, BCACP: DIRECTOR OF DISPENSARIES (DOD)Ohio native Scott Miglin has been advocating for and educating patients as a community pharmacistfor nearly 25 years. He brings skills and expertise that are critically important to overseeing dispensaryoperations, ensuring regulatory compliance and meeting the needs of Ohio’s qualified patients.Mr. Miglin is recognized by the Board of Pharmacy Specialties as a Board-Certified Ambulatory CarePharmacist (BCACP). Such recognition denotes his ability to educate patients with multiple diseasesrequiring highly complex drug regimens and to recommend appropriate adjustments in medications ordosages to maximize benefits and minimize adverse drug reactions. As research into cannabis asmedicine expands, his extensive knowledge of pharmacology, therapeutics and pharmacokinetics willbe invaluable to the translation of research into increasingly effective OGT therapies and relatedpatient education.Licensed as a pharmacist in Ohio and Missouri, Mr. Miglin has more than two decades of experienceoperating pharmacies. As DOD, he is positioned to ensure OGT’s dispensaries run in a mannerenvisioned by the Board of Pharmacy.
ANDREW WEIL, M.D.: CHIEF SCIENCE OFFICER & CHAIRMAN OF SMADr. Weil is clinical professor of Medicine and professor of Public Health at the University of Arizona andfounder and director of the university’s Center for Integrative Medicine. He is a nationally respectedauthority on integrative therapies in patient care. He conducted the first published human trials oncannabis, and has worked closely with principal investigators in NIH sponsored clinical trials ofcannabinoids and cancer. He is an internationally recognized expert on medicinal plants andintegrative medicine and an author of numerous scientific articles and books on psychoactive
substances. His nearly 50 years as an educator and medical researcher lend an unparalleled ability toprovide expert training for OGT dispensary staff.
JEFFREY MCELROY, PH.D., SCIENCE ADVISOR: SMA MEMBERDr. McElroy has 40 years of experience in commercial agriculture including medical cannabisproduction. He has extensive global experience in botany and plant breeding, including researchingand developing new plant varieties. He has directed cultivation operations at a medical cannabisproduction and dispensary in Maine and is the Chief Cultivation Advisor for Maui Grown Therapies,located in Hawaii.
JUSTIN FISCHEDICK, PHD: SCIENCE ADVISOR; SMA MEMBERDr. Fischedick is a biochemist and owner and lead analyst at Excelsior Analytical Laboratory in UnionCity, CA, which specializes in rigorous scientific analysis of cannabis products. He has authored or co-authored scientific articles on cannabis, cannabinoids and terpenoids published in top scientific andmedical journals. He has presented his scientific research at a number of national and internationalconferences including the Phytochemical Society of North America conference, the InternationalConference on Natural Products Research and the International Association for Cannabinoids asMedicine (IACM) conference.
DONALD ABRAMS, M.D.: CHIEF MEDICAL OFFICER; SMA MEMBERDr. Abrams is a 20-year researcher of the efficacies of cannabis on human health. His studies forcannabis research have been funded by the NIDA, NIH and the University of California. Receiving adegree in molecular biology at Brown University and his medical degree from Stanford University, Dr.Abrams now serves as Chief of Hematology and Oncology at San Francisco General Hospital andProfessor of Clinical Medicine at the University of California San Francisco.
MICHAEL BACKES: CURRICULUM AND TRAINING ADVISOR; SMA MEMBERMichael Backes is a specialist in cannabis science and the endocannabinoid system. and collaboratesclosely with our Director of Dispensaries in the development of our educational and training materialsfor staff and patients. He is founder and former director of the Cornerstone Research Collective, thenation’s first evidence-based medical cannabis dispensary. He is the author of Cannabis Pharmacy:The Practical Guide to Medical Marijuana, the first objective, evidence-based guide to addressingmedical conditions with cannabis therapeutics based on strain and chemotype.
JAMES B. PEAKE, M.D., LT. GEN. (RET): SMA BOARD MEMBERIn 2004, Dr. Peake retired from a 42-year career in the United States Army. He is a former U.S.Secretary of Veterans Affairs (2007-09) and former U.S. Army Surgeon General. He is a graduate ofWest Point and the Cornell University Weill Cornell Medical College where he was awarded a medicaldoctorate. He has a strong interest in the potential benefits of medical cannabis for veterans sufferingfrom post-traumatic stress syndrome, traumatic brain injury and other service-related disabilities.
Operations Plan(Dispensary Oversight)
D-1.1 By selecting "Yes", the Applicant attests that it will appoint a designated representativeresponsible for the oversight, supervision and control of operations of the medical marijuanadispensary. When there is a change in the appointed designated representative, the Applicant willnotify the State Board of Pharmacy within 10 business days of appointment. OAC 3796:6-3-05 YES
1.2.3.4.5.6.7.8.
Operations Plan(Security and Surveillance )
D-2.1 By checking “Yes,” the Applicant attests that it is able to continuously maintain effective security,surveillance and accounting control measures to prevent diversion, abuse and other illegal conductregarding medical marijuana and medical marijuana products.
D-2.2 Please provide a summary of the Applicant's proposed security and surveillance equipment andmeasures that will be in place at the proposed facility and site. These measures should cover, but arenot limited to, the following:
General overview of the equipment, measures and procedures to be usedAlarm systemsSurveillance systemSurveillance storageRecording capabilityRecords retentionPremises accessibilityInspection/servicing/alteration protocols
Please reference OAC 3796:6-3-16 for more information.
D-2.2.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-2.2. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered.
YES
This response has been entirely redacted
Uploaded Document Name: D-2.2.1_Security and Surveillance3.pdfNOTE: This applicant uploaded document is the next 5 page(s) of this document.
D-2.3 By selecting “Yes”, the Applicant attests that the answer provided in response to Question D-2.2is voluntarily submitted to the State Board of Pharmacy in expectation of protection from disclosure asprovided by section 149.433 of the Revised Code. YES
Operations Plan(Receiving of Product)
D-3.1 By selecting "Yes", the Applicant attests that it is able to safely and securely receive medicalmarijuana and medical marijuana products.
D-3.2 By selecting "Yes", the Applicant attests that it will implement standard operating procedures toinspect, prior to accepting any medical marijuana. Defective products must be rejected. Defectiveproducts include, but are not limited to the following: expired, damaged, deteriorated, misbranded oradulterated medical marijuana. OAC 3796:6-3-06; OAC 3796:8
D-3.3 Please describe the Applicant's processes, procedures, and controls regarding the inspection ofmedical marijuana from cultivators and processors prior to accepting any delivery at the proposeddispensary. Include a description of the proposed space for delivery and inspection. OAC 3796:6-3-06
YES
YES
D-3.3.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-3.3. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: D3.3.1_Receiving of product3.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
1.2.3.4.5.6.
Operations Plan(Storage of Product)
D-4.1 There will be separate, locked, limited access areas for the storage of medical marijuana that isexpired, damaged, deteriorated, mislabeled, contaminated, recalled, or whose containers or packaginghave been opened or breached, until the medical marijuana is returned to a cultivator, or processor,destroyed or otherwise disposed.
D-4.2 All storage areas will be maintained in a clean and orderly condition and free from infestation byinsects, rodents, birds, and pests.
D-4.3 A separate and secure area for temporary storage of medical marijuana that is awaiting disposalwill be established.
D-4.4 Please describe the Applicant's plans regarding the storage of medical marijuana within theproposed dispensary. The plan should include, but is not limited to, descriptions of the following:
Oversight of medical marijuana storagePhysical security measuresRecord maintenancePersons who will have access to medical marijuanaClimate control and lighting maintenance, including any necessary equipmentSanitation of storage areas
Please reference OAC 3796:6-3-07 for more information.
YES
YES
YES
D-4.4.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-4.4. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: D4.4.1_Storage of product3.pdfNOTE: This applicant uploaded document is the next 2 page(s) of this document.
Operations Plan(Dispensing of Product)
D-5.1 By selecting "Yes", the Applicant attests that it is prepared and willing to join the AmericanSociety for Automation in Pharmacy (ASAP) annually in order to facilitate near-real-time reporting tothe Ohio Automated Rx Reporting System (OARRS). American Society for Automation in Pharmacy; OAC 3796:6-3-08; OAC 3796:6-3-10
D-5.2 By selecting "Yes", the Applicant attests that it will use the patient registry to verify theregistration of a patient or caregiver. OAC 3796:6-3-08
D-5.3 Please indicate the expected number of Patient Registry scanners needed for the Applicant'sfacility (Information Only).
D-5.4 By selecting "Yes", the Applicant attests that it will have at least two employees physicallypresent at the dispensary location, one of whom is a dispensary key employee, when the dispensary isopen for the sale of medical marijuana. OAC 3796:6-3-03
D-5.5 Please describe the Applicant's processes, procedures, and controls regarding the dispensing ofmedical marijuana, updating the patient record, and product labeling. Describe how these will besupported by the Applicant's internal inventory system including integration with the state inventorytracking system and for reporting to OARRS using the current ASAP format. Please attach a sampleproduct label, with any identifiable information redacted or anonymized. OAC 3796:6-3-08; OAC3796:6-3-09; OAC 3796:6-3-10
YES
YES
3 (three)
YES
D-5.5.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-5.5. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: D-5.5.1_Dispensing of product3.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
1.2.3.
Operations Plan(Inventory Management of Product)
D-6.1 By selecting "Yes" the Applicant attests that it will establish inventory controls and procedures forthe conducting of weekly inventory reviews and annual comprehensive inventories of medicalmarijuana at the facility. OAC 3796:6-3-20
D-6.2 By selecting "Yes" the Applicant attests that its written or electronic weekly and annual inventoryrecords described in D-6.1 will include:
The date of the inventoryA summary of the inventory findingsThe employee identification numbers, and titles or positions, of the individuals who conductedthe inventory
Please reference OAC 3796:6-3-20 for more information.
D-6.3 By selecting "Yes", the Applicant attests that it will use the state inventory tracking system. ORC3796.07; OAC 3796:1-1-01; OAC 3796:6-3-06
D-6.4 By selecting "Yes" the Applicant attests that it will maintain records of medical marijuanareceived from a cultivator or processor in its internal inventory control system. OAC 3796:6-3-20
D-6.5 By selecting "Yes" the Applicant attests that it will maintain records of medical marijuanadispensed to a patient or a caregiver in its internal inventory control system. OAC 3796:6-3-08
D-6.6 By selecting "Yes" the Applicant attests that it will maintain records of expired, damaged,deteriorated, misbranded, or adulterated medical marijuana awaiting return to a cultivator / processoror awaiting disposal, in its internal inventory control system. OAC 3796:6-3-20
D-6.7 Please provide an explanation for selecting "No" in response to questions D-6.1 through D-6.6
D-6.8 Please describe the Applicant's approach regarding the implementation of an inventorymanagement process. This approach must also include a process that provides for the recall ofmedical marijuana and the management of medical marijuana product returns from the proposeddispensary to the originating cultivator and/or processor. OAC 3796:6-3-20
YES
YES
YES
YES
YES
YES
No response provided by applicant
D-6.8.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-6.8. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: D-6.8.1_Inventory management.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
1.2.3.4.
D-6.9 Please describe the Applicant's processes, procedures and controls regarding a patient orcaregiver’s ability to return unused medical marijuana for the purpose of dispossession and destroying.Include, at a minimum, a description of
How patients and caregivers will be charged for such returnsHow returns will be trackedHow any returned medical marijuana will be secured at the facilityThe maximum amount of time that returned medical marijuana will be stored at the facility
D-6.9.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-6.9. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: D-6.9.1_Patient returns.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Operations Plan(Diversion Prevention of Product)
D-7.1 Please provide a summary of the procedures and controls that the Applicant will implement atthe dispensary for the prevention of the unlawful diversion of medical marijuana, along with the processthat will be followed when evidence of theft/diversion is identified. OAC 3796:6-3-01; OAC 3796:6-3-05; OAC 3796:6-3-16
1.2.3.4.
Operations Plan(Sanitation and Safety)
D-8.1 Please provide a summary of the intended sanitation and safety measures to be implemented atthe dispensary. These measures should include, but are not limited to, plans, procedures, and controlsto address the following:
Processes for contamination preventionPest protection proceduresInstruction to dispensary employees regarding the handling of medical marijuanaHand-washing facilities
Please reference OAC 3796:6-3-02 for more information.
1.
2.3.4.5.6.7.
Operations Plan(Record-Keeping)
D-9.1 By selecting “Yes,” the Applicant attests that it will notify State Board of Pharmacy at least 7 daysprior to rendering medical marijuana unusable. All waste and unusable product will be weighed,recorded and entered into both its internal inventory system and in the state inventory tracking system.The destruction of medical marijuana will be witnessed by a key employee and conducted in adesignated area with fully functioning video surveillance. OAC 3796:6-3-14
D-9.2 Please provide a summary of the Applicant’s record-keeping plan at the dispensary. This planshould cover, but is not limited to, a description for how the following records will be maintained:
Employee records, including a background check conducted by the proposed dispensary andtraining provided by the proposed dispensaryOperating procedures and controlsAudit recordsStaffing plans; Business recordsSurveillance recordsAttendance logsQuality assurance review logs
Please reference OAC 3796:6-3-17 for more information.
YES
Operations Plan(Other )
D-10.1 Please provide a summary of any other services or products to be offered by the Applicant atthe dispensary. OAC 3796:6-2-02
D-10.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-10.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: D-10.1.1_Other services and products.pdfNOTE: This applicant uploaded document is the next 4 page(s) of this document.
D-10.2 Please provide a summary of intended services for veterans and/or the indigent. OAC 3796:6-2-02; OAC 3796:6-3-22
D-10.3 Describe the Applicant's efforts to minimize the environmental impact of the proposeddispensary. OAC 3796:6-2-02
D-10.3.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in D-10.3. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: D-10.3.1_Environmental.pdfNOTE: This applicant uploaded document is the next 1 page(s) of this document.
Operations Plan(Security & Infrastructure Records )
D-11.1 By selecting "Yes", the Applicant attests that all responses identified as containing security andinfrastructure are voluntarily submitted to the State Board of Pharmacy in expectation of a protectionfrom disclosure as provided by section 149.433 of the Revised Code. YES
Patient Care(Staff Education and Training)
E-1.1 Describe the Applicant's education and training plan and how it will meet the foundational andongoing training required for dispensary employees to be authorized to dispense medical marijuana.Include a summary of the substantive training content, the number of hours each dispensary employeewill receive for each mandatory training requirement, the number of training hours each dispensaryemployee will receive for any elective training, and the anticipated source of each type of trainingdescribed. OAC 3796:6-3-19
E-1.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-1.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: E-1.1.1_Staff education and training.pdfNOTE: This applicant uploaded document is the next 3 page(s) of this document.
E-1.2 Summarize how the Applicant's training plan will identify and incorporate advancements inmedical marijuana research. Include a description of the frequency with which the training plan will beupdated, how new information will be incorporated into the training plan, the method for providingupdated training to dispensary employees, and the frequency with which updated training will beprovided to dispensary employees. OAC 3796:6-3-19
E-1.2.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-1.2. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: E-1.2.1_Staff education advancements.pdfNOTE: This applicant uploaded document is the next 2 page(s) of this document.
1.2.3.4.5.
Patient Care(Patient Care and Education)
E-2.1 Describe how dispensary employees will be trained to provide patient education regarding:Recognizing the signs of abuse or adverse events in the medical use of marijuanaInstruction on use of medical marijuana to treat a qualifying conditionRisks associated with medical marijuana, including possible drug interactionsGuidelines for support to patients related to the patient's symptomsGuidelines for refusing to provide medical marijuana to an individual who appears to beimpaired or abusing medical marijuana. Include the sources of the training and the sources'qualifications to provide such training.
Please reference OAC 3796:6-3-19 for more information.
E-2.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-2.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: E-2.1.1_Patient care and education.pdfNOTE: This applicant uploaded document is the next 3 page(s) of this document.
1.2.
3.
E-2.2 Describe the Applicant's processes, procedures and controls addressing reports of adverseevents. Include, at a minimum, a description of:
How reports will be documentedThe circumstances that will require reports of adverse events will be reported to a cultivator,processor, and / or the State Board of PharmacyThe time frame for which to provide such reports
1.2.3.4.
Patient Care(Patient Care Facilities)
E-3.1 Describe the adequacy of the size of the proposed dispensary to serve the needs of patients andcaregivers, including building and construction plans with supporting details. Such plans shall illustrate,at a minimum, the size and location of the following within the prospective dispensary location:
The dispensary departmentRestricted access areasWaiting roomPatient care areas or other areas designated for patient and caregiver consultation andinstruction. Include a summary of the patient flow through each area, the maximum patientand caregiver occupancy in each area at any given time, the amount of time the Applicantexpects to interact with both new and returning patients, and the number of dispensaryemployees who will staff each area
Please reference OAC 3796:6-2-02 for more information.
E-3.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measuresdescribed in E-3.1. The images or diagrams may contain a brief descriptive caption. Additionallanguage responding to the question will not be considered. Uploaded Document Name: E-3.1.1_Patient care facilities3.pdfNOTE: This applicant uploaded document is the next 2 page(s) of this document.
Patient Care(Dispensary Operating Hours)
E-4.1 By selecting "Yes", the Applicant attests that it will make the dispensary available to patients andcaregivers to purchase medical marijuana for a minimum of 35 hours per week, between the hours of 7am and 9 pm, except as authorized by State Board of Pharmacy. OAC 3796:6-3-03
E-4.2 Provide the proposed hours of operation during which the prospective dispensary will available todispense medical marijuana to patients and caregivers. (Information only) OAC 3796:6-3-03
YES
7 am to 9 pm
Patient Care(Patient Information)
E-5.1 By selecting "Yes", the Applicant attests that it will post a sign directing patients and caregiverswith medical marijuana inquiries or adverse reactions to the toll-free hotline established by the StateBoard of Pharmacy. OAC 3796:6-3-15
E-5.2 By selecting "Yes", the Applicant attests that it will make information regarding the use andpossession of medical marijuana available to patients and caregivers. The Applicant agrees to submitall such information to the State Board of Pharmacy prior to being provided to patients and caregivers. OAC 3796:6-3-15
YES
YES
Attestations and Acknowledgements(Attestations and Acknowledgements)
F-1.1 Fill out and attach the “Trade Secret Form” to Question F-1.1, specifying the question and / orattachment references of the application submission that are exempt from disclosure under Ohio publicrecords law and articulate how the information meets the definition of “trade secret” under OhioRevised Code section 1333.61(D). If no material is designated as trade secret information, a statementof “None” should be listed on the form. Uploaded Document Name: F-1.1 Trade Secret Form App3.pdfNOTE: This applicant uploaded document is the next 7 page(s) of this document.
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Explanation and Justification of Trade Secret Designations
Section 1331.61, Ohio Revised Code defines a trade secret as follows:
"Trade secret" means information, including the whole or any portion or phase of any scientific or technical information, design, process, procedure, formula, pattern, compilation, program, device, method, technique, or improvement, or any business information or plans, financial information, or listing of names, addresses, or telephone numbers, that satisfies both of the following:
(1) It derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use.
(2) It is the subject of efforts that are reasonable under the circumstances to maintain its secrecy.
Information identified in records by its owner as a trade secret is not automatically exempted from disclosure under R.C. 149.43(A)(1)(v) of the Public Records Act as “records the release of which is prohibited by state or federal law.” State Ex Rel. Besser v. Ohio State University, 87 Ohio St.3d 535, 540 (Ohio 2000). Rather, identification of a trade secret requires a fact-based assessment. “An entity claiming trade secret status bears the burden to identify and demonstrate that the material is included in categories of protected information under the statute and additionally must take some active steps to maintain its secrecy.” Fred Siegel Co., L.P.A. v. Arter & Hadden, 85 Ohio St.3d 171, 181 (1999) (finding that the time, effort, or money expended in developing a law firm’s client list, as well as amount of time and expense it would take for others to acquire and duplicate it, may be among factfinder’s considerations in determining if that information qualifies as a trade secret). The Ohio Supreme Court has adopted the following factors in analyzing a trade secret claim: “(1) The extent to which the information is known outside the business; (2) the extent to which it is known to those inside the business, i.e., by the employees; (3) the precautions taken by the holder of the trade secret to guard the secrecy of the information; (4) the savings effected and the value to the holder in having the information as against competitors; (5) the amount of effort or money expended in obtaining and developing the information; and (6) the amount of time and expense it would take for others to acquire and duplicate the information.” State ex rel. Besser v. Ohio State Univ., 89 Ohio St.3d 396, 2000-Ohio- 475, citing State ex rel. The Plain Dealer v. Ohio Dept. of Ins. (1997), 80 Ohio St.3d 513, 524-525, 687 N.E.2d 661, 672. The maintenance of secrecy is important but does not require that the trade secret be completely unknown to the public in its entirety. If parts of the trade secret are in the public domain, but the value of the trade secret derives from the parts being taken together with other secret information, then the trade secret remains protected under Ohio law. Besser, 89 Ohio St. at 399-400. Trade secret law is underpinned by “[t]he protection of competitive advantage in private, not public, business.” State ex rel.
Toledo Blade Co. v. Univ. of Toledo Found., 65 Ohio St.3d 258, 264 (1992).
2
Further, Ohio’s trade secret law protects information in all forms, including trade secrets in hard-copy or electronic form, regardless of electronic-storage medium, including social media; and even those trade secrets that have been committed to an employee’s memory. Al Minor & Associates, Inc. v. Martin, 227 Ohio St.3d 58 (2008). This underlying information is important because Applicant has developed processes and procedures for the dispensing of marijuana, security and surveillance, employee qualifications and training, storage of medical marijuana products, inventory management, recordkeeping, prevention of medical marijuana diversion, as well as financial projections and cost structure information, including projected costs and expenses of dispensary operations and staffing, that fit squarely within the scope of trade secret protection under Ohio law. These processes, procedures and information are not generally known outside of Applicant; they are known only to those individuals inside Applicant’s business that have a need to know and are subject to contractual limitations on use and disclosure; Applicant has taken substantial precautions to guard the secrecy of this information; these processes, procedures and information are extremely valuable and are not known to competitors; they were developed by Applicant through the expenditure of substantial effort and money; and independent development of these processes and procedures by competitors would require the expenditure of substantial time, effort and expense. Ohio courts have recognized that trade secret protection extends to these kinds of processes, procedures and information. See, e.g., Exal Corporation v. Roeslein & Associates, Inc., Case No. 4:12cv1830, Memorandum of Opinion and Order (U.S District Court, Northern District of Ohio 2013) (recognizing that trade secret protection may apply to financial projections and cost structure information, including without limitation production, labor, material, facility, utility, and other operational information fundamental to design, construction, and operations; information concerning the identity and method of use of all raw materials used by in operations, including without limitation chemicals, temperatures and settings; necessary adjustments and settings required to facilitate proper operations; and operational information and materials shared, collected, and reviewed in the creation of maintenance manuals and standard operating procedures). Each of these answers to questions and related attachments identified as TRADE SECRET set forth confidential trade secret processes and procedures for the dispensing of marijuana, confidential trade secret standard operating procedures, confidential trade secret information regarding personnel and their roles in the organization and/or confidential trade secret financial projections and cost structure information relating to costs and expenses of dispensary operations and staffing. Pursuant to R.C. 149.433 of the Revised Code, this information is voluntarily submitted to a public office in expectation of protection from disclosure as provided by section 149.433 of the Revised Code. Applicant acknowledges that the State of Ohio does not assume liability for the use or disclosure of unmarked or unclearly marked trade secret information.
F-1.2 To be considered complete, each application must be submitted with an Attestation and ReleaseAuthorization. The form must be completed by a Prospective Associated Key Employee who maylegally sign for the Applicant and who can verify the information provided in the application is true,correct, and complete. This response has been entirely redacted