HomeMy WebLinkAboutSignature PageLansing City Clerk’s Office
Ninth Floor, City Hall, 124 W. Michigan Ave., Lansing, MI 48933-1695
517-483-4131 • 517-377-0068 FAX
www.lansingmi.gov/clerk • city.clerk@lansing.mi.gov
S:\Clerk_Staff\Licenses\Medical Marihuana\MM Procedures & Forms\Medical Marihuana Provisioning Center Application.docx
Page 5 of 7
I affirm that I, the applicant, and each stakeholder and employee is at least 18 years of age and has not
been convicted of or pled guilty or no contest to a disqualifying felony. 1300.5(B)(4)
I affirm that I, the applicant or operator: 1300.5(B)(7)
have not had a business license revoked or suspended.
or
have had a business license revoked or suspended, explained below:
I acknowledge that I, the applicant, am aware that all matters related to marihuana, growing, cultivation,
possession, dispensing, testing, safety compliance, transporting, distribution, and use are currently
subject to State and Federal Laws, Rules, and Regulations and that the approval or granting of a
license hereunder does not exonerate or exculpate myself, the applicant, from abiding by the provisions
and requirements and penalties associated with those laws, rules, and regulations or exposure to any
penalties associated therewith; and further myself, the applicant, waives and forever releases any
claim, demand, action, legal redress, or recourse against the City of Lansing, its elected and appointed
Officials and its Employees and Agents for any claims, damages, liabilities, causes a result of the
violation by myself, the applicant, its Officials, members, partners, shareholders, employees and agent
of those laws, rules, and regulations and hereby waives, and assumes the risk of any such claims and
damages, and lack of recourse against the City of Lansing, its elected and appointed Officials,
employees, attorneys, and agents. 1300.5(B)(24)
I swear that neither I, the applicant, nor any stakeholder is in default to the City of Lansing for failure to
pay any property taxes, special assessments, fines, fees or other financial obligation to the City. 1300.5
(B)(21)
I agree to report any changes to the information required under Chapter 1300 to the City Clerk within
ten (10) business days. 1300.8(D)
I understand that a grant of a conditional license by the City of Lansing is contingent upon the grant of
a license by the State of Michigan.
I swear that the statements made in this application, including all attachments thereto, are true.
Name __________________________________ Signature __________________________________________
Address _____________________________________________ Date _________________________________
Subscribed & sworn to before me this _____day of ________________20_____
Notary Signature__________________________________________________
Printed Name______________________ My Commission Expires___________
Notary Public, _________County, MI Acting in the County of______________