Colorado Department of Revenue

Medical Marijuana Enforcement Division

Forms Packet

Revised July 11, 2011

MMED July 8, 2011

This Packet contains information and revised forms to give Applicants guidance necessary for compliance to rules which are effective July 1, 2011. Additionally, we have provided documents that you may choose to use or you may use as an indication of what records or data you are expected to keep in order to be in compliance. You may already capture this information and can generate a report and therefore the use of the specific MMED form may not be necessary. This is a work in progress and any one of these forms may be modified in the future, so please ensure you are using the current version of the form by checking our web site – dates posted will be reflected next to the link to the form. Specifically, the form revisions include: additional instructions, removal of unnecessary information and clarification of required information. If you have already submitted the old version of the forms, you do not have to resubmit them, but please use the new forms going forward. All Center, Infused Product Manufactures and Cultivation businesses are required to submit two forms by July 15, 2011: their employee list (form 1000) and patient list (form 1010). If your employees have not obtained their licenses prior to submittal of this list enter pending on the License Number column. The employee list and patient lists must be submitted to the MMED on a monthly basis thereafter. Please do not submit any personal data about patients; include only the fields shown on the forms. In addition, effective July 1, 2011, all centers must use the Medical Marijuana Transportation Manifest Form (form 1020), the Employee Status Change Form (form 1030), and the Patient Status Change Form (form 1040). The past few weeks we have had two issues that have been legitimate problems for businesses trying to come into compliance and the MMED has determined to make accommodations which do not affect our regulation capabilities those accommodations are:

10.400 3. Specific Standards, IP Camera Table Housing Rating) After consideration of concerns from the industry, an accommodation for Exterior Fixed Cameras to move from a Housing Rating of IP67 to an IP66 is allowed with the understanding that we may require the installation of a Heater and/or Blower on each camera affected, should the functionality be below our standards. 10.400 4. Equipment, Paragraph g) the 9600 dpi requirement has been reinterpreted to read “The licensee must be able to immediately produce a clear color still photo from any camera image (live or recorded). Each facility shall have a minimum of one color printer that produces a high quality, recognizable image of video surveillance images

As we have had before and will say again, we focused on building a fair, unambiguous and transparent regulatory system for the Colorado Medical Marijuana Industry and we appreciate your willingness to work with us as we all move forward together. Form may be faxed to 303-205-2398 Or mailed to: MMED Form Submission 455 Sherman Street, Suite 390 Denver, CO 80202

MMED investigators will soon begin visiting Medical Marijuana Centers (MMC’s), Optional Premise Cultivations (OPC’s) and Marijuana Infused Product (MIP’s) establishments to conduct inspections for licensing. Listed below is a list of some of the areas of concern that investigators will be focusing on. This list is not all-inclusive and all Medical Marijuana industry owners and employees are encouraged to become thoroughly familiar with all provisions of the statutes and rules promulgated by the State Licensing Authority. The rules promulgated by the state licensing authority go into effect on July 1, 2011. The MMED investigators will be conducting both announced and unannounced visits on establishments throughout Colorado.

Limited Access Areas Identified (Proper signs posted) Properly displayed license(s) (local & state-issued medical marijuana licenses and

sale tax license(s) as well as any other required license(s) All employees displaying proper MMED-Issued credentials MMED investigators will be making observations regarding on-premise use of

cannabis by patients and/or employees Security Alarm System, which is compliant with MMED rules Commercial-grade, non-residential locks, which is compliant with MMED rules Video surveillance of all required areas, including areas where marijuana is

possessed, stored, grown, harvested, cultivated, cured, sold, entrances and exits with logging and limited access to equipment, which is compliant with MMED rules

List of all licensed employees Diagram of licensed area Proper record-keeping of patients and inventory related to patients (both plant

count and finished product). Ability to demonstrate compliance with 70%-30% rule

Proper record-keeping of all sales (both to primary patients and other sales to non-primary patients)

Employees conform to hygienic practices Preparation areas; surfaces, utensils and equipment are adequately cleaned and

kept clean Inspection of cleaning compounds, sanitizing agents, pesticides and insecticides

to ensure that no banned and / or hazardous chemicals are on the premise Waste is stored and secured in a manner which is compliant with MMED rules Waste that is rendered unusable should be grinded with non-consumable solid

waste and disposed of, which is compliant with MMED rules All product is properly labeled and identified for retail sales Labeling standards from 7/1/11 rules must be met Complete all sales between 8:00AM and 7:00PM (7:05PM is not acceptable)

Do not transport Medical Marijuana without a MMED approved Manifest in place

Additional information can be found at: http://www.colorado.gov/cs/Satellite/Rev-Enforcement/RE/1251575119584

MEDICAL MARIJUANA ENFORCEMENT DIVISION REQUIRED FORMS AND REPORTS

Following are revisions to the forms and reports previously posted on the MMED website. The revisions include additional instructions and clarifications, combining or eliminating in some instances, redundant data, and significant changes to the 70/30 report. NOTE: If you have previously submitted the required information on forms published June 16, 2011, you do not need to resubmit on the revised forms. However, please use the revised forms after July 1, 2011. These forms and reports contain information required by the Medical Marijuana Enforcement Division (MMED). Suggested sample formats are provided. With the exception of the Medical Marijuana Transportation Manifest Form and the 70/30 Compliance Check Report, if your system or procedures create reports or forms that contain the information on the forms below you do not have to use the suggested format. Please note: not all forms/ reports included in this packet need to be submitted to the MMED. In addition, the only form that can be submitted via email is the Medical Marijuana Transportation Manifest Form. Do not email any of the other forms. Information contained on these forms is considered the minimum necessary for internal control purposes. It is the Licensee’s responsibility to ensure that all required forms/reports contain the minimum required information. As we progress with the internal control minimum procedures (ICMPs) we will post additional forms and instructions on the MMED website. Mail or fax forms to: Medical Marijuana Enforcement Division

455 Sherman St. Suite 390 Denver, CO 80203 Fax: 303-205-2398

FORMS AND REPORTS TO SUBMIT TO MMED BY JULY 15, 2011: Form 1000 - Employee List Report Licensees are required to document all employees on the Employee List Report. For subsequent employee status change(s), see the “Employee Status Change Form”. The Employee List Report should be submitted to the MMED on a monthly basis (due on the first business day of each month). 12-43.3-310 (2) and (4) Form 1010 - Monthly Primary Center Patient List The Monthly Primary Center Patient List documents patients who registered the Center as the Primary Center. Per statute, a center may posses 6 plants for each registered patient. For patient status changes, see the “Patient Status Change Form”. The Monthly Primary Center Patient List should be submitted to the MMED on a monthly basis (due on the first business day of each month). 12-43.3-901(4)(e) and Rule 1.205(A)(1) FORMS AND REPORTS TO USE AND SUBMIT TO MMED ON AND AFTER JULY 1, 2011: Form 1020 - Medical Marijuana Transportation Manifest Form (this format is required) The licensee must submit the Medical Marijuana Transportation Manifest form at least 24 hours prior to the transportation (via vehicle) of any medical marijuana to the MMED. This form can be sent by email to MMEDmanifest@dor.state.co.us or fax to 303 205 – 2398. Rule 11.200(D)

MEDICAL MARIJUANA ENFORCEMENT DIVISION REQUIRED FORMS AND REPORTS

Form 1030 - Employee Status Change Form The licensee must report any change(s) in an employee’s status to the Medical Marijuana Enforcement Division within ten (10) days of the change. 12-43.3-901(3)(d), 12-43.3-310(3), and Rule 16.105 Form 1040 - Patient Status Change Form The licensee must report any change(s) in a patient’s status to the Medical Marijuana Enforcement Division within seventy-two (72) hours of the change. 12-43.3-601(2), Rule 1.200 FORMS AND REPORTS TO USE AND MAINTAIN EFFECTIVE JULY 15, 2011 (DO NOT SUBMIT TO MMED, BUT HAVE AVAILABLE FOR MMED INSPECTION): Licensees must complete and maintain the following forms/reports. Do not submit to the MMED. Form 1050 - Secure Facility Form The licensee must complete the Secure Facility Form for each installation of the security/video surveillance systems at each business location to the Medical Marijuana Enforcement Division. The system layout must be included with this form. 12.43.3-202(2)(x), Rule 10.400(B)(1)(c) Form 1060 - 70/30 Compliance Check Report (this format is required) The licensee must update the 70/30 Compliance Check Report on a monthly basis. 12-43.3-402(4), Rule 1.210 (A-E) Form 1070 - Transfers, Sales and Purchases (Monthly Summary) Licensees are required to complete the Transfers from Grow and Purchases Report on a monthly basis for all grow transfers, sales and purchases. 12-43.3-701 (1-2) Form 1080 - Wholesale Transaction Report (Daily Summary) Licensees are required to complete the Wholesale Transaction Report for all wholesale purchases and sales transactions on a daily basis. 12-43.3-701 (1-2) Form 1090 - Transfers from OPC Report (Daily Summary) Licensees are required to complete the Transfers from Grow Report for transfers from the Grow (OPC) to the Medical Marijuana Center (MMC) or Medical Infusion Plant (MIP). If the transfer is within contiguous properties, then a Medical Marijuana Transportation Manifest Form is not required. 12-43.3-701 (1-2) Form 1100 - Patient Sales Report (Daily Summary) Licensees are required to complete the Patient Sales Report for all patient sale transactions on a daily basis. 12-43.3-701 (1-2) Form 1110 - Wholesale Transaction Form Licensees are required to complete and document the prenumbered Wholesale Transaction Form for all wholesale sales and purchase made to and from MMC’s or MIP’s. 12-43.3-701 (1-2)

MEDICAL MARIJUANA ENFORCEMENT DIVISIONEMPLOYEE LIST REPORT

Business Licensee Name

Enter business licensee name

Business Licensee / Application Number

Enter business licensee/application number

Date of ReportEnter effective date of report

THE EMPLOYEE LIST REPORT IS DUE MONTHLY. PLEASE FAX THIS REPORT TO 303-205-2398 BY THE FIRST BUSINESS DAY OF EACH MONTH

Employee License # Employee Last Name Employee First Name

Enter employee Medical Marijuana Key or Support license # Enter Employee Last Name Enter Employee First Name

*Change in employee status MUST be reported to the Medical Marijuana Enforcement Division by completing the Employee Status Change Form within ten (10) business days and faxing to 303-205-2398

Attach completed EMPLOYEE STATUS CHANGE FORMs if necessary.

Form 1000MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISIONMONTHLY PRIMARY CENTER PATIENT LIST

Please submit ONLY the fields shown on this form. Do NOT send any other personal information about patients.

Reporting Month

Enter month reporting

Business Licensee Name

Enter business licensee name

Business Licensee /Application Number

Enter business license/application number

The Patient List Report is due monthly. Please fax this report to 303-205-2398 by the first business day of each month. Changes in patients status MUST be reported to the Medical Marijuana Enforcement Division by faxing the Patient Status

Change Form within seventy-two (72) hours to 303-205-2398.

Patient ID Number Patient Card Expiration Date

Primary Center Designation Date

Maximum Plants Per Patient *

Initials of the person making the change

Enter patient ID number from registry card

Enter patient card expiration date

Enter effective date of primary center designation

Enter maximum number of plants authorized for patient

Enter initials of person making the change

Total Plant Count enter total of maximum number of plants authorized for patients listed on this report

* For each patient with a plant count greater than 6, the licensee must maintain additional documentation from the recommending physician as required per C.R.S 12-43.3-901(4)(e).

Licensee must send MMED completed PATIENT STATUS CHANGE FORMs.

Form 1010MMED form rev 7/2011

Form 1020 MMED form rev 7/2011

Medical Marijuana Enforcement Division Medical Marijuana Transportation Manifest

All sales transactions are to be completed prior to transportation of any Medical Marijuana. The receiving Center may reject product delivered, but amount delivered must be limited to amount agreed upon in prior sales transaction. If the route contains multiple stops, a separate manifest is required for each delivery.

Fax to 303-205-2398 or Email to MMEDmanifest@dor.state.co.us

Name of Originating Entity:

License Number of Originating Entity:

For MMED Use Only:

Date Completed:

Address and Phone Number of Originating Entity:

Name of Destination Entity:

License Number of Destination Entity:

Address and Phone Number of Destination Entity: Email Address or Fax Number to Which MMED Approved Copy is to be sent:

Phone Number MMED Can Call With Questions:

Product Being Delivered (Circle any rejected portion of shipment. Check here if page two is used to list additional product)

Grams (for MMC and OPC) or

Quantity (for MIP) Batch #

Date and Approximate Time of Departure:

Date and Approximate Time of Arrival:

Route to be traveled. Check here if the route has multiple stops (multi-stop routes require a separate manifest for each delivery): Vehicle: Make, Model and License Plate Number:

Name of Person Transporting:

Signature of Person Transporting: Date of Signature:

Product Rejection (if only a portion of shipment is rejected, circle that portion above.)

Name of Person Receiving or Rejecting Product:

Date:

I confirm that the contents of this shipment match weight records entered above, and I agree to take custody of this those portions of this shipment not circled above. Those portions circled were returned to the individual delivering this shipment. Signature:

Signature of Individual taking receipt of rejected portions of this shipment:

Medical Marijuana Enforcement Division Medical Marijuana Transportation Manifest

Product Being Delivered (Continued from page 1. Circle any rejected portion of shipment)

Grams (for MMC and OPC) or

Quantity (for MIP) Batch #

Form 1020 MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISIONEMPLOYEE STATUS CHANGE FORM

Business Name Business License Number DateEnter legal business name Enter business Medical Marijuana registration license number Enter effective date of change

Employee License Number Employee Last Name Employee First NameEnter employee Key or Support license number Enter employee's last name Enter employee's first name

Signature of Key licensed employee making change

Signature

I attest that the information above is complete and accurate to the best of my knowledge, and understand that employee status changes must be reported to the Medical Marijuana Enforcement Division within 10 (ten) days. Per C.R.S 12-43.3-310 (3) .

The purpose of this document is to notify the Medical Marijuana Enforcement Division of status changes for the employee of my business as listed below:

Change of Status - check all that apply Name Change Employee License Number Change New Hire Terminated Employee Other

Please Explain:List details of change marked above (Name Change, New Hire, etc.). Include old information and new information where applicable.

Enter date form signed

Date

*Change in employee status MUST be reported to the Medical Marijuana Enforcement Division by completing the Employee Status Change Form within ten (10) business days and faxing to 303-205-2398

Form 1030MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISIONPATIENT STATUS CHANGE FORM

ange Form

The purpose of this document is to notify the Medical Marijuana Enforcement Division of status change(s) for the patient of my business as listed below:

Today's Date

Enter date form is completed

Effective Date

Enter date change is effective

Business Licensee NameEnter business licensee name

Business Licensee/Application Number

Enter business licensee/application number

Changes in patients status MUST be reported to the Medical Marijuana Enforcement Division by completing the Patient Status Chwithin seventy-two (72) hours and faxing or emailing the form to the appropriate MMED center.

Patient ID Number Patient Card Expiration Date Primary Center Designation Date

Sta(e.g

Primary

tus Change . ID #, plant limit, Center designation)

# of Plants for this Patient

Enter ID # from patient's card Enter patient card expiration date Enter primary center designation date Enter status change details Enter # of plants for patient

Please Explain Status Change Below:Provide additional information necessary to clarify or document patient status change or plant # if it exceeds six.

* For each patient with a plant count greater than 6, the licensee must maintain additional documentation from the recommending physician as required per C.R.S 12-43.3-901(4)(e).

I attest that the information above is complete and accurate to the best of my knowledge

Form must be signed by key employee accepting and reporting change Enter title of key employee reporting change

Signature Title

Enter date signed by key employee

Date

Form 1040MMED form rev 7/2011

Medical Marijuana Enforcement Division Secure Facility Form

All Medical Marijuana Businesses operating with the State of Colorado must install security/video surveillance systems in each business location. Attach system lay-out to this form. Licensees must maintain completed form and attachments. Do not submit to the MMED.

LICENSED BUSINESS INFORMATIONDate Submitted:

License Number:

Business Name: Physical Address: Owner’s Name and Contact Information:

SECURITY VENDOR (IF OUT-SIDE CONTRACTOR USED) Business Name: Responsible Party or Owner: Address: Phone Number:

SYSTEM SPECIFICS IP Access Address for MMED Access to Surveillance System: DVR or NVR Product Used (Manufacturer and Model Number) : Location of Off-Site Security Video Storage: Name of 24 Hour Contact for Business: (include: Landline; cell phone; email address; home location if available)

Form 1050 Revised 070111

MEDICAL MARIJUANA ENFORCEMENT DIVISION 70 / 30 COMPLIANCE CHECK REPORT

For the 12 Months Ending (add month and year)

Form 1060 MMD form rev 7/2011Form 1060 MMD form rev 7/2011

Business Licensee Name

Business Licensee Number

Record in Grams Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 YTDEnter amounts from the Transfers, Sales and Purchases Monthly Report

Grams Sold to Patients (A)

Wholesale Sales in Grams (B)

Total Sales in Grams (C) = (A+B)

Wholesale Purchases in Grams (D)

Wholesale Transaction % (12 month year must not be greater than 30%)

[ ( B + D ) / ( A /.7 ) ]

Maximum wholesale transactions allowed [(A/0.7)*0.3]

Wholesale transaction grams (B+D)

Over (Under) maximum

I attest that the above amounts are complete and accurate to the best of my knowledge

Print Name and Title Print Name and Title

Signature and Date Signature and Date

MEDICAL MARIJUANA ENFORCEMENT DIVISION TRANSFERS, SALES, AND PURCHASES

MONTHLY SUMMARY

Month:

Business Licensee Name

Business Licensee Number

DateTransfers from OPC

(in grams)Patient Sales

(in grams)Wholesale Purchases

(in grams)Wholesale Sales

(in grams)

Enter Transaction date (NA if no transactions for

the day)

Enter total grams transferred from the Transfers from OPC Daily Summary Report (form

1090)

Enter total grams sold to patients from the Patient

Sales Daily Summary Report (form 1100)

Enter total grams of wholesale purchases from the Wholesale

Transaction Daily Summary Report (form 1080)

Enter total grams of wholesale sales from the Wholesale

Transaction Daily Summary Report (form 1080)

Enter Reporting Month

Enter Business Licensee Name

Enter Business Licensee/Application number

Monthly Totals*

Total of monthly transfers Total monthly patient sales Total monthly wholesale purchases Total monthly wholesale sales

* Monthly totals should tie to the 70/30 Compliance Check Report (form 1060)

I attest that the above amounts are complete and accurate to the best of my knowledge.

Enter Key Employee name and title

Print Name and Title

Enter Key Employee's signature and date of review

Signature and Date

Form 1070 MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION WHOLESALE TRANSACTION REPORT

Daily Summary

Date

Enter date of transactions

Business Licensee Name

Enter business licensee name

Business Licensee/Application Number

Enter business licensee/application number

This form is to be used for all Wholesale Transactions: Purchases and Sales.

Transaction Number StrainWeight

Purchas Quantity - ed (in grams)

Weight Quantity - Sales (in grams) Batch # Employee License # Employee Initials

Enter transaction number as assignelicensee

d by Enter strain Enter quantity purchased in grams Enter quantity purchased in grams Enter batch number Enter employee License # Enter employee initials

Daily Totals

* Daily totals should tie to the Transfers, Sales, and Purchases Summary (form 1070)

I attest that the above amounts are complete and accurate to the best of my knowledge.

Enter name and title of key person responsible for compliance

Print Name and Title

Enter signature of above individual and date signed

Signature and Date

Form 1080 MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION TRANSFERS FROM OPC REPORT

Daily Summary

Form 1090 MMED form rev 7/2011Form 1090 MMED form rev 7/2011

Business Licensee Name

Business Licensee #

Date of Transfer

Strain Product Description Batch # Weight Qu

(in gramantity s)

EmLice

(from

ployee nse # OPC)

Employee Initials

EmLic(C

ployee ense #

enter or MIP)Employee

Initials

Enter information and amounts of Medical Marijuana (in grams) or number of plants transferred from the Grow to the Center

Total

* Daily total should tie to the Transfers, Sales, and Purchases Summary (form 1070)

I attest that the above amounts are complete and accurate to the best of my knowledge

Print Name and Title (Originating Entity) Print Name and Title (Destination Entity)

Signature and Date (Originating Entity) Signature and Date (Destination Entity)

MEDICAL MARIJUANA ENFORCEMENT DIVISION PATIENT SALES REPORT

Daily Summary

Daily Patient Sales Report

Date

Enter date of sales

Business Licensee Name

Enter Business Licensee Name

Business Licensee/Applicant Number

Enter Business License/Applicant #

Transaction Number Patient ID Number Strain Batch # Weight Quantity

(in grams) Employee License

Number Employee InitialsEnter transaction number as assign

licenseeed by Enter Patient Registry # Enter strain description Enter batch # Enter quantity Enter employee License # Enter employee initials

Daily Totals

Enter total grams sold

* Daily total should tie to the Transfers, Sales, and Purchases Summary (form 1070)

I attest that the above amounts are complete and accurate to the best of my knowledge

Enter name and title of employee responsible for report

Print Name and Title

Enter signature and date of employee responsible for report

Signature and Date

Form 1100 MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISIONWHOLESALE TRANSACTION FORM

Date of TransactionEnter Transaction Date Transaction #

Sold To:MMC or MIP Name

Enter Business Licensee Name

MMC or MIP License/Applicant Number

Enter Business Licensee/Applicant #

Strain Product Description Batch #

Weight Quantity (in grams ) Unit Price

Total Extended

Price

Enter Strain Description Enter Product Description Enter Batch # Enter Weight in Grams

Enter Unit Price for Product

Weight Quantity Multiplied by Unit

Price

Totals

(This Section for Inventory c ) Purposes - Pur haser copy

Date of TransactionEnter Transaction Date Transaction #

Purchased From:

MMC or MIP NameEnter Business Licensee Name

MMC or MIP License NumberEnter Business Licensee/Applicant #

Strain Product Description Batch #

Weight Quantity (in grams ) Unit Price

Total Extended

Price

Enter Strain Description Enter Product Description Enter Batch # Enter Weight in Grams

Enter Unit Price for Product

Weight Quantity Multiplied by Unit

Price

Totals

I attest that the above amounts are complete and accurate to the best of my knowledge

Enter Name and Title of Responsible Employee Enter Name and Title of Responsible Employee

Print Name and Title (Seller) Print Name and Title (Purchaser)

Signature and Date of above Individual Signature and Date of above Individual

Signature and Date Signature and Date

Notes: - The transaction number should be a unique, consecutive number assigned by licensee for each transaction . - The top copy for the Seller; the bottom copy for the Purchaser.

Form 1110 MMED Rev 7/2011