New Application Change of Employee Information Change of Employer Information Employer Business Location Address: ZIP: Employer Cannabis License #: EMPLOYMENT INFORMATION Employer Name: Employer Phone #: Pick One Full Time Part Time Seasonal Pick One Professional/Managerial General Worker Security Primary Job Responsibilities: DECLARATIONS Have you ever been convicted of a crime? Yes No Have you ever been issued a cannabis permit by another agency? Yes No If yes, provide permit type, permit number, City/County of issuance, issuance date and expiration: Do you own or operate any other businesses in the City of Lancaster? Yes No If yes, provide business license numbers for each business owned: EMPLOYEE INFORMATION Name Alias Phone Business Phone Email Address SSN# or FEIN# Date of Birth DL #, State, Exp. Home Address City State Zip ACKNOWLEDGEMENT By signing below, I hereby authorize the City of Lancaster, its employees and agents to seek verification of the information contained within the application. Additionally, I provide authorization for the City of Lancaster to utilize data retrieved from local, state, and federal law enforcement, and judicial entities to conduct a criminal history check within sixty (60) days of the submission of this application. Data received pursuant to the background check shall be presumed valid. I understand that any incompleteness or falsification of any fact may result in a denial of this application or revocation of any license issued. I DECLARE UNDER PENALTY OF PERJURY OF THE STATE OF CALIFORNIA THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT AND THAT I HAVE RECEIVED A COPY OF ORDINANCE NO. 1053 [LMC CHAPTERS 5.56 AND 17.43], UNDERSTAND ITS CONTENTS, AND UNDERSTAND THE DUTIES AND RESPONSIBILITIES OF AN EMPLOYEE OF A CANNABIS MANUFACTURING AND/OR CULTIVATION FACILITY. If a license is issued, the applicant agrees to and will comply with all applicable state laws and regulations (even if more restrictive than the City’s and as they may be amended from time to time), including, without limitation. Additionally, the applicant agrees to and will coordinate with all governmental agencies. AN APPLICANT SHALL NOT COMMENCE EMPLOYMENT UNTIL A BUSINESS LICENSE HAS BEEN ISSUED. EMPLOYEE MUST KEEP EMPLOYEE LICENSE IN THEIR POSSESSION AT ALL TIMES WHILE WORKING IN A CANNABIS FACILITY. BUSINESS LICENSES ARE RENEWED ANNUALLY. CANCELLATION OR RENEWAL OF A BUSINESS LICENSE MUST BE SUBMITTED IN WRITING. ALL PROVISIONS OF THE LANCASTER MUNICIPAL CODE, COUNTY CODES, AND APPLICABLE FEDERAL AND STATE LAWS MUST BE COMPLIED WITH BEFORE BUSINESS CAN BE LAWFULLY CONDUCTED. I UNDERSTAND THAT INTENTIONALLY PROVIDING FALSE INFORMATION MAY BE A BASIS FOR DENIAL OF A LICENSE AND CONSTITUTES PERJURY. This application must be completed in its entirety and signed by the employee of the proposed cannabis cultivation and/or manufacturing facility. SIGNATURE Name Title Date
