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    Schedule A forms from application for Arkansas Medical Cultivation and Dispensary permit applications.

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    Schedule A forms from application for Arkansas Medical Cultivation and Dispensary permit applications.

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    331 views54 pages

    00001-00020 Redacted

    Uploaded by

    Russ Racop
    Schedule A forms from application for Arkansas Medical Cultivation and Dispensary permit applications.

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    of 54
    O00 APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. GENERAL INFORMATION 1 Name of Applicant (Must be a natural perscn,) 2. Business Name: HOT SPRINGS MEDICAL. Fictitious Trade Name (if any): DBA HOT SPRINGS MEDICAL Business Mailing Ae Business telephone number: +1-50~ 3. Business entity type: SOLE PROPIETORSIUJP DOING BUSINES AS (DBA\ Date of business formation or incorporation: 12 JULY 2017 State(s) of Formation: ARKANSAS Registered Agent Name: N/A Registered Agent Address: NA. 4, List all owners, stockholders, shareholders, members, officers, and board members of the proposed dispensary. Idemtify the nature of the individual's or corporation's affiliation with the proposed dispensary and percentage of ownership, if'any. NC ease make sure that 100% of the ownership interest in the proposed dispensary is accounted for in this section. (Attach any necessary additional pages to this form. Include « header on any attachinents. The header for this response should include “Section A. Number 4.”) £100 0-0 5. County of Proposed Location: GARLAND COUNT’ 6. City of Proposed Location (II inside eity limits): N/A 7. Has the applicant or business entity filed, or does the applicant or business entity intend to file an additional application for a dispensary license under the same or a different name at a different location? If s0, please provide the location(s) and any other name under which the application(s) will be made TION SUBMITTED FOR ZONE 5, SDICAL, WEEDON CEMETARY ROA! 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicants(s) for dispensarics/cultivation centers? If yes, please identify the individual and the name of the proposed cultivation facility or GOOo1 dispensary, and briefly describe the nature of the relationshi TORSHIP Certification |, . ¢000i) that the information provided in this form and its attachments is complete and accurate. [ understand that any misstatement or concealment of fact may be grounds for refusal of application or revocation of licence if later disclosed. Signed this__Q7__ day of July, 2012 ty to before me this 2) day of July, 2017. Buwl stonids __ My Commission Expires: | >b “2094 Subscribed and s ey, comm. £x87- OOo A APPLICATION FOR MEDICAL MAREUANA DISPENSARY SECTION, & NERAL INFORMATION 1, Name of Applicant (Must be a natural person.) 2. Husiness Name _NSK Medical Exchange, LLC. Fictitious Trade Name (if any )_Natural State of Kind Business Mailing Address i Business telephone number 501-408-2420 3. Business entity type _LLC Date of business fo ation oF incorporation_August 7. 2017 State(s) of Incorporation _AR. Registered Agent Name _Jason Martin Registered Agent Address _ 400 W. Capitol Ave., Sulte 1700, Little Rock, 1700, Little Rock, AR 72201, J. List all owners, stockholders, shareholders, members, officers, and board members of the poration’s affil with the proposed dispensary and percentage of ownership, if any. NOTE: Please make sure that 100% of the ownership proposed dispensary. Identify the nature of the individual's or © lerest in the proposed dispensary is accounted for in this ary culditional pages to this form, Include atlachmants, he header for this response should inelade "Seetion A, Number 4.") ‘Owner Applicant - 51%" own RII 2221 06 0” wader 01 WE Do erver=0%0° SN = Goo a er BR - 8013 werdor 0% 5. County of Proposed Locat n Faulkner 6. City of Propased Location (Ifinside city limits]_Conway (1) CONFOENTIAL ¢ OKRA 7, Has the applieant or business entity filed, or does the applicant or business eatity intemd to file an additional application for a dispensary license under the same or a different name at a different location? Ifsa, please provide the location(s) and any other name under which the application(s) will be made. ‘Appicant and comp late ownership are filing applications for additional dispensaries under the same ‘company nae. 8. Isthe Applicant or uny owner, stockholder, sharcholder, officer, or board member in any way affitinted with any other applicants(s) for dispeasariescultivation centers? IT yes, please identify the individual and the name of the proposed cultivation facitity or dispensary, and bricfly deseribe the nature of the relationship. Applicant and complete ownership are filing applications for 2 cultivation under the company ‘ame NSK Agriculture LLC Conti 1 corsity thatthe information prowided inthis form and iS attachments is complete and accurate, | understand that any misstatement or concealment of fact imay be grounds for refusal of application or revocation of license i tater disclosed sivnea nis__©f th day of iungture of Applicant d } t i y Subscribed and sworn to before me this __f_dayot_f fel w 87 Notary Publ My Commission Expires: Ao? AL D622 CHERYL SHOOK ey COMMISSION ZIERI5E EXPRES Deon IP 2006 (tune Courty (1) CONFIDENTIAL cows APPLICATION FOR MEDICAL MARIJUANA DISPENSARY NA. GENERAL INFORMATION 1, Name of Applicant (Must be a aataral person.) 2. Business Name Qup o Coffee. Inc, fi ious Trade Name rary) Business Mailing Address _Newport, AR 72112. Business telephone number 979.247.6542 or 870.503.3154 _ 3. Dusiness entity type_Type@ C Corp Date of business formation or incorporation__O1/12/47 State(s) of Incorporation _ Arkansas Registered Agent Name Tim Watson, Jr. Attorney Registered Agent Address \ 44 4 List all owners, stockholders, shareholders, members, aficers, proposed dispensary. Identity the anture of the individual's or corporation's affiliation wit’ the proposed dispensary and persentoge of ownership, ifany. NOTR: Please make sure (hat 100% of the ownership intorest in the proposed dispensary is accounted far in this scetion. (Attach any necessary additional pages to this forim, Include a header om arty attachments. The header for this response should tnctode “Section A. Number 4.") | 60% Partner EE AQ% Barines. 5. County of Proposed Location Jackson. ao V 81 SnV i 6. City of Proposed Location (if inside city limits) _ Newport :aAIZO3Y Oooo, Has the applicant or business entity filed, or does the applicant or business entity intend to file an additional application for & dispensary liceuse under the same or a different name st different location? If so, please provide the location(s) and any other name under which the application(s) will he made No 8, Isthe Applicant or any owner, stockholder, shareholder, officer, er board member in any way affilinted with any other applicants(s) for dispensaries/cultivation centers? IT yes, please identify the individual and the name of the proposed cultivation facility or Gispensary, and briefly deseribe the nature of the relationship. No L certify thal the information provided in this form aod its attachments fs complete anc sccurate, I understand that any misstaremen’ or concealment af fac ray be grounds for refusal of application or revocation of license i ater disclosed epace toy ane emacs ey ( 4 OC0OU APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY SECTION A. GENERAL INFORMATION 1, Name of Applicant (Must be a natural person.) 2. Business Name Arkansas Medical Marijuana Farm LLC. Fictitious Trade Name (if any). Address MMMM or Smith. AR. 72916 mber 479-424-1100 Oftce, ines entity type _Limited Liablity Company Date of business formation, incorporation_June §.2017 State(s) of Incorporation ___ Arkansas Registered Agent Name _simmy Lee Didier I Registered Agent Address _ 8601 Howard Hil Road. Fort} ¢ Cone, 4, List all owners, stockholders, sharcholders, members, officers, and board members of the proposed cultivation facility. {dentify the nature of the individual's or corporation's affiliation with the proposed cultivation facility and the percentage of ownership, if any. NOTE: Please make sure that 100% of the ownership interest in the proposed cultivation facility is accounted for in this section. (Attach any necessary additional pages to this form. Include a header on any attachments. The header for this response should include “Section A. Number 4.") See attached Exhibit (Section A Number 4) ” County of Proposed Location__Sebastian > City of Proposed Location (If inside city limits)__NA 7. Has the applicant ar business entity filed, or does the applicant or business entity intend to file an additional application for a cultivation facility license, under the same or a different name at a location? If so, please provide the location(s) and any other name under which the application(s) will be made. 8. Is the Applicant or any owner, stockholder, sharcholder, officer, or board member in any way affiliated with any other applicant(s) for DUL0~| dispensaries/eultivation centers? If yes, please identify the individual and the name of the proposed cultivation facility or dispensary, and briefly describe the nature of the relationship. No Cenit || . certify thut the information proviuled in this form and its atachments fs complete and accurate, I understand that any misstatement or conevalment of fact may be grounds tor refusal of applicatian or revocation of license if later ation disclosed. aA! Signed this EXHIBIT EXHIBIT FOR SECTION A, NUMBER 4 Names and Addresses of Owners of Fort Smith Investment Partners, LLC ME oper tc 8601 Howard Hill Road Fort Smith, AR 72916 rt Smith Investment Partners. LLC 46001 Howard Hill Road ‘rt Smith, AR 72916 Properties, 1 8601 Howard Hill Road Fort Smith. AR 72916 Membership | Interest (ity Member & Percentage Ownership ; Percentage Ownership Living Teust UFI/D Living Trust UTD 42772012 (12.80%) | 4/27/2012 (12.50%) tity Meniber | Entity Member & ge Ownership Entity Member Percentage Ownership | Percents Living Trust UTD 2 (6.66%) Living Trust UTYD 4/27/2012 (6.66%) Svoner 007 MMA, LLC 8112 Mile Tice Drive Fort Smith, AR 72903 UDA fivestments. LC 3436 Philpor Road Ozark, AR 72040 Hideaway Homes. 114 3001 Mekiniey Ave. Fort Smith, AR 72908, Fort Smith Legacy. LLC 6108 Park Ave. Fort Smith AR P2903 PCU Belle Point Ventures. 11.€ 4100 South 34" Stcet Hort Smith. AR 7290 TORGRACE. TTC 6304 Free Ferry Road Fort Smith. AR 72903 OO (6.66%) a (3.33%) (2.33%) ra) a be 12001 Rye {ill Read Fort Smith, AR 72916 Scotch Ladies. LLC 17 Berryhill Road Fort Smith, AR 72903 Reserved Percentag Charitable purposy and/or Medical | Cannabis Education | (6.66%) ¢ c 000% APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. GENERAL INFORMATION 1. Name of Applicant (Must be a natural person.) 2. Business Name _Arkansas Medical Marijuana Farm LLC. Fictitious Trade Name (iFany), Business Mailing Address Fort Smith, Arkansas 72916. Business telephone number _ 479-424-1100 Ofice, J 3. Business entity type__Limited Liabilty Company n__ dune 5.2017 Date of business formation or ineorpora Statels) of Incorporation Arkansas Repistered Agent Name Jimmy Lee Didier It 1d Hill Road, Fort Smith, AR. 72916 Registered Ageat Address 4. List all owners, stoekholders, shareholders, members, officers, and board members uf the propased dispensary, Ientify (he nature of the individual's or corporation's affiiation with the proposed dispensary and percentage of ownership, if any, NOTE: Please make sure that 100% of the ownership interest in the proposed dispeosary is necounted Cor in this (Attach any necessary additional pages to this form. Include a header on any \ler for this response should includ: "Section A. Number 4.) mcachments. The hea See attached Exhibit (Section A. Number 4) 5. County of Proposed Location __ Sebastian 6 City of Proposed Location (If inside city |imits)__ Fort Smith, Arkansas 7. Has the applicant or business entity filed, or does the applicant or business entity intend to file an additional application for a dispensary license amder the same or a different name at a different location? If so, please provide the lneation(s) and any other name under which the application(s) sill be made. NO 8. Isthe Applicant or any owner, stockholder, shareholder, officer, or board member in any way affitiated with any other applicants(s) for dispensariesfeultivation centers? If yes, please identify the individual and the name of the proposed cultivation facility or dispensary, and briefly deseribe the nature of the relationship. No. Conitiearion cently that the information provided in this fixm hd iis attachments is complete and accurate. Vmderstand {or concealment oF kick smiay be grounds for reflesal oF application or revca sh : c sienewhis_ IO _eay(r Seroui AMS EXHIBIT | XHIBIT FOR SECTION , NUMBER 4 ‘Names Fort Smith Investment Partners, LLC THB Properties. 1-¢ 8601 Howard Hill Road Fort Smith, AR 72916 Smith investment Partners. LLC [Road 2916 Fort Smith. AR 7 sof Owners of | Membership Interest Entity Member | & centage Ownership a Living Trust U/T/D 4/27/2012 (12.50% “Entity Member & Percentage Ownership Entity Member & Percentage Ownership Living Trust W/T/D 4/27/2012 (12.50 Entity Member & Percentage Ownership Properties, LLC 8601 Howard Hill Road Fort Smith. AR 72916 Living Teust U/T/ 421202 (6.66%) Sooner 007 MMAILC 8112 Mile Tree Drive Fort Smith, AR 7290: TDA tnvestments, CC 3436 Philpor Road Ovark, AR 72949 Hideaway Homes, LLC 3001 MeKinley Ave. Kort Smith. AR 72908 Fort Smith Legacy. LLC 6105 Park Ave. Fort Smith. AR 72903, PCU Belle Point Ventures. LLC 4100 South 34" Street Fort Smith. AR 72901 a 66.) G.33%) a 6.65%) Living Trust U/T/D H2TI2O12 (6.66%) a «5: (3.33%) (6.66%) ey TORGRACE, LLC 6304 Free Ferry Rond Fort Smith. AR 72903, 12001 Rye Hill Road Fort Smith, AR 72916 Scotch Ladies. LEC 17 Rerryhil] Road mith, AR 7200. Fort Reserved Parentage for Charitable purpose and/or Mi ( 60%) APPLICATION FOR MEDICAL MARIJUANA CULTIVATION FACILITY 2 SECTION A. GENERAL INFORMATION Name of Applicant (Must be a natural person.) hE Business Name _NSK Agriculture, LLC. Fictitious Trade Name (if any)_Natural State of Kind Business Mailing Address SII MII WM. tic Rook, AR 72201 Business telephone number _ 501-408-2420 . Business entity type LLC Date of business formation or incorporation_August7, 2017 State(s) of Incorporation _AR Registered Agent Name _Jason Martin Registered Agent Address _400 W. Capitol Ave., Suite 1700, Little Rock, AR 72201 C : occa 4. List all owners, stockholders, shareholders, members, officers, and board members of the proposed cultivation facility. Identify the nature of the individual's or corporation's affiliation with the proposed cultivation facility and the percentage of ownership, ifany. NOTE: Please make sure that 100% of the ownership interest in the proposed cultivation facility is accounted for in this section. (Attach any necessary additional pages to this form. Include a header on any attachments. The header for this response should include “Section A. Number 4.") MR © O12 ppticant 51% VME « Owrer- 5% VMI - Ovsner - 14.5% ME - 0 06°- 5% AMM « Ovrne = 14.5% I «08 r-50 ME « Owe 5% AMEE 8603 ember - 0% MMM ~ B0200 Nemba: - 0% I 80274 Merrbor- 0% RR «06202 verve -0% MI ~ 80216 Member - 0% - (UR = 82216 order 0% MN «22276 Werner _0% MER «6024 Momoer 0% S. County of Proposed Location_Jackson 6. City of Proposed Location ([f inside city limits)_N/A 7. Has the applicant or business entity fited, or does the applicant or business entity intend to file an additional application for a cultivation facility license, under the same or a different name at a different location? If so, please provide the location(s) and any other name under which the application(s) will be made. No 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member in any way affiliated with any other applicant(s) for (1) ONDER dispensaries/cultivation centers? If yes, please identify the individual and the name of the proposed cultivation facility or dispensary, and briefly describe the nature of the relationship. Appiicant and complete ownership are filing applications for a dispensary under the company name. NSK Medical Exchange, LLC. Certification L ctf that the information provided in this is complete and accurate. I understand that any misstatement or nse if later form and its attachments concealment of fact may be grounds for refusal of application or revocation of i disclosed. Signed this Gg ih day ot (Legenda DIT Signatére of Appl ‘cribed and swom to before me this S day of _SieeG tp. 1} CONFDENTIAL weer err re ~~ ~~ -- Ay 0000 + APPLICATION FOR MEDICAL MARIJUANA DISPENSARY SECTION A. GENERAL INFORMATION 1. Name of Applicant [Must be a natural person.) _—_ a. 2. Business Name___The Hemp Store Café, | Fictitious Trade Name (if any]__N/A Business Mailing Address Mountain View, Arkansas 72560 Business telephone number __ 501-350-7663 _(temporan 3. Business entity type _ Medical Cannabis Dispensary with $0 plant grow Date of business formation or incorporation _08/25/2017. State(s) of Incorporation __Arkansas ee Registered Agent Name ___Charles &. Widmer Rogistered Agent Address __713 Fvans Street, Mountain View, Arkansas 72560 4. List all owners, stockholders, shareholders, members, officers, and board members af the proposed dispensary. Identify the nature of the individual's oF corporation's affiliation ‘with the proposed dispensary and percentage of ownership, if any. NOTE: Please make sure that 100% of the ownership interest in the proposed dispensary is accounted for in this section. (Attach any necessary additional pages to this form. include a header on any attachments, The header for this response should include “Section A. Number 4.”) or, _ owner — We Fowner = 39.3399 7e owner = (le 33.3333 7 7 5. County of Proposed Location 6. Chy of Proposed Location (IFinside city imits)_))& ‘ i Oo? 7, Hus the applicant or business entity filed, or does the applicant or business entity intend to file an additional application for a dispensary licetise under the same or a different name at ferent location” IF'so, please provide the location(s) and any other name under which 5) will be mace, 8. Is the Applicant or any owner, stockholder, shareholder, officer, or board member In any way afliliated with any other applicants(s) for dispensaries/cultivation centers? If please identify the individual and the name of the proposed cultivation facitity or dispensary, and briefly describe the nuture of the relationship. Nia Medien Comes Le. 0 cultivar o vy apilicast Orage sas. Vale ing 2 LLC i D2 ounce of Datta Medical Cannabis Company LUE.

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