medical marijuana enforcement division forms

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Colorado Department of Revenue

Medical Marijuana Enforcement Division

Forms PacketJune 16, 2011



This Packet contains information and forms to give Applicants guidance necessary forcompliance to rules which are effective July 1, 2011. With one exception – the travel manifest -we have provided documents that you may choose to use or you may use as an indication of whatrecords or data you are expected to keep in order to be in compliance. You may already capturethis 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 thefuture, 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.

In regard to the Travel Manifest form you must use the form provided and it must be sent to ouroffice for approval 24-hours (during the work week, be sure to accommodate weekends andholidays in this calculation) prior to the actual transportation of the product takes place. Theform may be sent to our office via fax (send to fax number 303-205-2398 or via email [email protected]

All Center, Infused Product Manufactures and Cultivation businesses should submit their

employee list to the MMED by July 1, 2011; if your employees have not obtained their licensesprior to submittal of this list enter pending on the License Number column. All centers shouldalso submit your patient list which must be complete as to reflect your Center’s paperwork.

This the past few weeks we have had two issues that have been legitimate problems forbusinesses trying to come into compliance and the MMED has determined to makeaccommodations which do not affect our regulation capabilities those accommodations are:

10.400 3. Specific Standards, IP Camera Table Housing Rating ) After considerationof concerns from the industry, an accommodation for Exterior Fixed Cameras to movefrom a Housing Rating of IP67 to an IP66 is allowed with the understanding that wemay require the installation of a Heater and/or Blower on each camera affected, shouldthe functionality be below our standards.

10.400 4. Equipment, Paragraph g) the 9600 dpi requirement has been reinterpretedto read “The licensee must be able to immediately produce a clear color still photo fromany camera image (live or recorded). Each facility shallhave a minimum of one color printer that produces a high quality, recognizable imageof video surveillance images

As we have had before and will say again, we focused on building a fair, unambiguous andtransparent regulatory system for the Colorado Medical Marijuana Industry and weappreciate your willingness to work with us as we all move forward together.

Forms may be faxed to 303-205-2398 or Mailed to our offices at: MMED Form Submission455 Sherman Street, Suite 390, Denver, CO 80202



MMED investigators will soon begin visiting Medical Marijuana Centers (MMC’s), OptionalPremise 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 investigatorswill be focusing on. This list is not all-inclusive and all Medical Marijuana industry owners andemployees are encouraged to become thoroughly familiar with all provisions of the statutes andrules promulgated by the State Licensing Authority. The rules promulgated by the statelicensing authority go into effect on July 1, 2011. The MMED investigators will be conductingboth 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 exitswith logging and limited access to equipment, which is compliant with MMEDrules

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



You MUST Provide an Email Address or Fax Number to Which MMED Approved Copy is to be sent:

Medical Marijuana Enforcement DivisionMedical Marijuana Transportation Manifest

All sales transactions are to be completed prior to transportation of any Medical Marijuana, receivingCenter may reject product delivered, but amount delivered must be limited to amount agreed upon in priorsales transaction. Fax form to 303-205- 2398 or email to [email protected]

Date Completed: License Number of Originating Entity:

Name of Originating Entity:

Location of Originating Entity:

Name of Destination Entity:

License Number of Destination Entity

Location of Destination Entity

Product Being Delivered(circle any rejected portion of shipment)

Weight Batch #

Date and Approximate Time of Departure Date and Approximate Time of Arrival

Route to be traveled:

Vehicle: Make, Model and License Plate Number

Name of Person Transporting:

Signature of Person Transporting

Date: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 takecustody of this those portions of this shipment not circled above. Those portions circled werereturned to the individual delivering this shipment.Signature:

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



Medical Marijuana Enforcement DivisionSecure Facility Form

All Medical Marijuana Businesses operating with the State of Colorado must install security/videosurveillance systems in each business location. Attached system lay-out to this form.Submit Form to:

Date Submitted: License Number

Business Name :Physical Address:

Owners Name and Contact Information:

SECURITY VENDOR (IF OUT -SIDE CONTRACTOR USED )Business Name:

Responsible Party or Owner:

Address:

Phone Number:Name and MMED License Number of Employee (s) installing system

SYSTEM SPECIFICS IP Access Address for MMED Access to Surveillance System:

DVR or NVR Product Used (Manufacturer and Model Number) :

Site of Off-Site Security Video Storage

Name of 24 Hour Contact for Business: (include: Landline; cell phone; email address;home location if available)



MEDICAL MARIJUANA ENFORCEMENT DIVISION70 / 30 COMPLIANCE CHECK REPORT

For the 12 Months Ending (add month and year)

Licensee Name:

Licensee Number:

Jan Feb Mar Apr May Jun Jul Aug Sep Oct

Beginning Inventory On-Hand in GramsIncreases

Transfers from Grow

Wholesale Purchases (A)

Adjustments (attach explanation)

Subtotal Increases

Total Gross Inventory On-Hand in Grams

DecreasesSales to Patients (B)

Wholesale Sales (C)

Adjustments (attach explanation)

Subtotal

Transfer to MIPS (100% for nonsmokables)

Ending Inventory On-Hand in Grams

Percentage Wholesale Purchases (A/B)

Percentage Wholesale Sales (C/B)

Total Wholesale Sales & Purchases(12 month year must not be greater than 30%)

Maximum wholesales based on sales

Actual wholesale purchase and salesOver (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 DIVISIONMONTHLY REPORTING EMPLOYEE LIST

Date

Reporting Month

Street Address City Zip New

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

*Change in employee status MUST be reported to the Medical Marijuana Enforcement Division within ten (10) days

Signature

Date

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

Number Employee First NameMust C

EmployeeLicense #

Employee Last NameEmployee Address

Licensee Name

Licensee Number



MEDICAL MARIJUANA ENFORCEMENT DIVISIONCHANGE IN EMPLOYEE STATUS

Business Name License Number Date

Employee License Number Employee Last Name Employee First Name

Street Address City Zip

Signature

Date

Change of StatusName Change Address Change Employee License Number Change

Terminated Employment Other

Please List New Information Below:

Please explain:

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 tothe Medical Marijuana Enforcement Division within 10 (ten) days.

Employee Address

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:

MMED form rev 7/2011



MEDICAL MARIJUANA ENFORCEMENT DIVISIONPRIMARY CENTER PATIENT LIST

Date Reporting Month

Number Patient ID Number Patient Card Expiration Date Primary Center DesignationDate

MaximumPlants PerPatient *

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Total Plant Count 0

* For each patient with a plant count greater than 6, additional documentation is required per C.R.S 12-43.3-901(4)(e).

Signature Title

Date

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

**Note: Change in patient status MUST be reported to the Medical Marijuana Enforcement Division within seventy-two (72) hours

Licensee Name

Licensee Number




MEDICAL MARIJUANA ENFORCEMENT DIVISIONPATIENT STATUS CHANGE FORM

Date Effective Date

Licensee Name

Licensee Number

Patient ID Number Patient Card Expiration Date Primary CenterDesignation Date

Status Change(e.g. ID #, plant limit,

Primary Center designation)

# of Plantsfor thisPatient

* For each patient with a plant count greater than 6, additional documentation is required per C.R.S 12-43.3-901(4)(e) .

Signature Title

Date

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

Please Explain Status Change Below:

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:

**Note: Change in patient status MUST be reported to the Medical Marijuana Enforcement Division within seventy-two (72) hours




MEDICAL MARIJUANA ENFORCEMENT DIVISIONWHOLESALE SALES REPORT

Daily Summary

Daily Wholesale Sales Report

Day Licensee Name and #

Transaction#

Licensee Name(Recipient)

Licensee Number(Recipient) Strain Product Description Batch #

WeightQuantity(in grams)

Unit Pricin gram

1

2

3

4

5

6

7

etc

Daily Totals na na na na na 0.00 na


Signature and Date

Print Name and TitlePrint Name and Title

Signature and Date



MEDICAL MARIJUANA ENFORCEMENT DIVISIONPATIENT SALES REPORT

Daily Summary

Daily Patient Sales Report

Licensee Name and #

Transaction# Patient ID # Strain Batch #

ProductDescription

WeightQuantity(in grams) Unit Price

To

1

2

3

4

5

6

7

etc

Daily Totals na na na na 0.00 na $


Print Name and Title


Print Name and Title



MEDICAL MARIJUANA ENFORCEMENT DIVISIONSALES SUMMARY REPORT

Monthly

Monthly Sales Report

Month: Licensee Name and #

DayDaily Patient Sales (in

grams) Totals1 0.002 0.003 0.004 0.005 0.006 0.007 0.008 0.009 0.00

10 0.0011 0.0012 0.0013 0.0014 0.0015 0.0016 0.0017 0.0018 0.0019 0.0020 0.0021 0.0022 0.0023 0.0024 0.00

25 0.0026 0.0027 0.0028 0.0029 0.0030 0.0031 0.00

Monthly Total s 0.00 0.00




0.00

Daily Wholesales(in grams)




MEDICAL MARIJUANA ENFORCEMENT DIVISIONWHOLESALE PURCHASES REPORT

Daily Summary

Daily Wholesale Purchases Report Licensee Name and #

Day:

Transaction #

Purchased from

Licensee Name

Purchased from

Licensee Number Strain

Product

Description Batch #

WeightQuantity

(in grams) Unit Price1234567etc

Daily Totals na na na na na 0.00 na




S:\Audit\Forms\Daily-Montlhly Purchases Report.xlsDaily Wholesale Purchases



MEDICAL MARIJUANA ENFORCEMENT DIVISIONTRANSFERS FROM GROW REPORT

Daily Summary

Daily Transfers from Grow to MMC or MIP

Day: Licensee Name and #

Strain Product Description Batch #Weight Quantity

(in grams)Employee ID #(from Grow)

EmployeInitials

Total na na 0.00 na na




S:\Audit\Forms\Daily-Montlhly Purchases Report _MT.xlsDaily Tranfers fr Grow



MEDICAL MARIJUANA ENFORCEMENT DIVISIONTRANSFERS FROM GROW and PURCHASES

Monthly

Month: Licensee Name and #

DayWholesale Purchases (in

grams) Totals1 - 0.002 0.003 0.004 0.005 0.006 0.007 0.008 0.009 0.00

10 0.0011 0.0012 0.00

13 0.0014 0.0015 0.0016 0.0017 0.0018 0.0019 0.0020 0.0021 0.0022 0.0023 0.0024 0.0025 0.00

26 0.0027 0.0028 0.0029 0.0030 0.0031 0.00

Monthly Total 0.00 0.00




Note: this should be a two-part form. One copy for the Transferor and the other for the Recipient.

0.00

Monthly Transfers from Grow and Wholesale Purchases

Transfers from OPC(in grams)

S:\Audit\Forms\Daily-Montlhly Purchases Report _MT.xlsMonthly Purchases-Transfers MMED form rev 7/2011



MEDICAL MARIJUANA ENFORCEMENT DIVISIONWHOLESALE TRANSACTION FORM

Sales Prenumbered

Licensee Name

Licensee Number

Date of Transaction

Sold to:MMC or MIP Name

MMC or MIP License Number

Strain

Product

Description Batch #

WeightQuantity(in grams )

Unit

Price

Total Extended

Price

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Totals na na 0.00 na -$


Print Name and Title (Licensee) Print Name and Title (MIP or MMC)


Note: This should be a prenumbered, two-part form. One copy for the Purchaser; one copy for the Seller.

MMED Rev 7/2011



MEDICAL MARIJUANA ENFORCEMENT DIVISIONWHOLESALE TRANSACTION FORM

Purchases Prenumbered

Licensee Name

Licensee Number

Date of Transaction

Purchase from:MMC or MIP Name

MMC or MIP License Number

Strain

Product

Description Batch #

WeightQuantity(in grams )

Unit

Price

TotalExtended

Price

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Totals na na 0.00 na -$


Print Name and Title (Licensee) Print Name and Title (MIP or MMC)


Note: This should be a prenumbered, two-part form. One copy for the Purchaser; one copy for the Seller.

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