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Waiver Request Form: Agent Registration CORI Report Requirement

Under 935 CMR 500.700, a Marijuana Establishment may request a waiver for Criminal Offender Record Information (CORI) report, which is otherwise required for individuals applying for registration as a marijuana establishment agent. 935 CMR 500.030(3). Written documentation is required to evaluate the waiver request. The request must be filled out and signed by an individual with authority or control over the management and operations of the Marijuana Establishment (Marijuana Establishment Representative). Before it is submitted, the request must be notarized and uploaded with the application for agent registration. Waiver Requested By The Following Marijuana Establishment Representative: Waiver Requested For The Following Marijuana Establishment Agent: _______________________________________________________ Agent’s Registration Application Number: Marijuana Establishment: Marijuana Establishment’s License/Application Number: _______________________________________________________ (1) Please provide the date of the last generated CORI report for the agent, which must have been issued

within the prior year:

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(2) Please provide the name of the entity and individual who reviewed the last generated CORI report:

(3) Under 935 CMR 500.700(1), a Marijuana Establishment may seek a waiver of a regulatory requirement, when compliance would cause undue hardship to the requestor; the requestor’s noncompliance does not jeopardize the health or safety of any patient or the public; and the requestor has instituted compensating features that are acceptable to the Commission. Please describe in detail the basis for seeking a waiver of the CORI report requirement:

(4) Please provide attestations from the Marijuana Establishment Representative identified above by

him/her initialing the following: a. A new CORI check for the proposed agent per 935 CMR 500.030(3) would cause an

undue hardship to the Marijuana Establishment;

b. The last report was generated within the previous 365 days and that a new CORI report will be generated prior to the one-year anniversary of the last report;

c. All required background check information on the CORI was reported in the agent

registration application identified above;

d. The last generated CORI report will be on file, securely and confidentially kept, for review by the Commission’s investigators or agents on request;

e. The individual attesting for the Marijuana Establishment reviewed the CORI report with the agent on and asked if there were any changes since that report. The agent did not report any changes since the issuance of the CORI report. The attesting individual is not aware of any changes since the issuance of the CORI report that would implicate the suitability of the applicant within the meaning of 935 CMR 500.800, 500.802, and 500.803

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(5) Please commit to obtaining a new CORI report by or before , which must be a date prior to the one-year anniversary date of the last issued CORI report.

I understand that under 935 CMR 500.031 (1) and (2), the Commission may deny a registration card on the ground that an applicant fails to provide the information required under 935 CMR 500.030, or provides misleading, incorrect, false, or fraudulent information. By signing this document, I affirm that all the information provided above is true and accurate including the required attestations referenced above. Marijuana Establishment’s Representative Printed Name: Marijuana Establishment’s Representative Signature: ____________________________________________________

AUTHENTICATION BY NOTARY PUBLIC

On this __________ day of ____________________, 2018, before me, the undersigned notary public,

personally appeared ______________________________________, proved to me through satisfactory

evidence of identification to be the person whose name is signed above and that he/she did so voluntarily

for its stated purpose.

__________________________________________ NOTARY STAMP/SEAL Notary Public Signature