SAMPLE 1

[Pages:2]SAMPLE 1

List of Facilities Applying for Licensure or Certification in Missouri to cultivate, manufacture, dispense or test medical marijuana that are or will be under substantially common control, ownership or management as the Applicant

Applicant:

Cultivator XYZ, LLC

Address:

123 Main Street, Jefferson City 65109

EIN:

84-1234567

Primary Contact: Joe Baker

Associated Entity Applying for Dispensary License

Dispense ABC, LLC EIN: 84-9876543 222 West End Street, Columbia MO 65201

Associated Entity Applying for Manufacturing License

Manufacturer ABC, LLC EIN: 84-9876333 222 West End Street, Northcity MO 65555

Ownership Allocation

Owners

Joe Baker Suzy Jones Bob Smith Chris McDonald

Total

Applicant Cultivator XYZ, LLC 27.00% 20.00% 23.00% 30.00%

100.00%

Related Entities Applying for Licensure

Dispense ABC, LLC

Manufacturer ABC, LLC

20.00% 2.00%

40.00% 38.00%

45.00% 0.00%

30.00% 25.00%

100.00%

100.00%

SAMPLE 2 No Common Control Response

List of Facilities Applying for Licensure or Certification in Missouri to cultivate, manufacture, dispense or test medical marijuana that are or will be under substantially common control, ownership or management as the Applicant

Applicant:

Cultivator 123, LLC

Address:

123 West Drive, Jefferson City 65109

EIN:

84-5555555

Primary Contact: Joe Baker

Ownership Allocation

I am the sole proprietor, with 100% ownership in the Applicant Entity. I do not have ownership or management in any other entity.

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