STATE OF NEVADARENO OFFICEDEPARTMENT OF TAXATION 4600 Kietzke Lane

Building L, Suite 235Web Site: https://tax.nv.gov Reno, Nevada 895021550 College Parkway, Suite 115 Phone: (775) 687-9999Carson City, Nevada 89706-7937 Fax: (775) 688-1303

Phone: (775) 684-2000 Fax: (775) 684-2020

STEVE SISOLAKLAS VEGAS OFFICE HENDERSON OFFICEGovernor

Grant Sawyer Office Building, Suite1300 2550 Paseo Verde Parkway, Suite 180555 E. Washington Avenue Henderson, Nevada 89074Las Vegas, Nevada 89101 Phone: (702) 486-2300

Phone: (702) 486-2300 Fax: (702) 486-2373 Fax: (702) 486-3377

JAMES DEVOLLDChair, Nevada Tax Commission

MELANIE YOUNG

License Renewal for Recreational Marijuana Establishment (ME)

NRS 453D.220(1) states that all marijuana licenses expire 1 year after the date of its issuance:

Except as otherwise provided in NAC453D.312, if a renewal application for a marijuanaestablishment satisfies the requirements of NAC453D.305 and the establishment is not disqualified from beinglicensed as a marijuana establishment pursuant to this section or other applicable law, the Department shallissue to the establishment a recreational marijuana establishment license. A marijuana establishment licenseexpires 1 year after the date of issuance and may be renewed upon:

(a) Resubmission of the information set forth in this section; and(b) Payment of the renewal fee set forth in NAC453D.200

InstructionsRegistration renewal application requirements:

1. Pay the renewal fee per NRS 453D.230. Mail a check or money order with the license applicationrenewal packet.

2. Complete the Renewal Application Form for Recreational Marijuana Establishment (ME) RegistrationLicense (this form) per R092-17 Sec.89 (2). Scan the form to a PDF document and name the file asfollows:ME ID#_renewal_app_MM_YYYY;Where the ME ID is the four digit code of the ME, and MM_YYYY is the two digit month and fourdigit year this renewal application is being submitted.

Example: D001_renewal_app_03_2018.pdf.Burn this PDF document to a renewal application CD-R disk or to a thumb drive.

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Executive Director

Entity Name:__________________ Establishment ID:_______ Tax Identification Number: (TID)_____________

3. Pursuant to NAC453D.305, Owners, Officers and Board members are required to submit fingerprintsto DOT at the following frequency:

a. Owners with greater than 5% aggregate ownership across all MEs of the same kind (i.e.cultivation, production, dispensary, distribution or lab) must submit fingerprints once in any 3year period.

b. Owners with 5% or less ownership interest in any one ME, or 5% or less when aggregated acrossall MEs of the same kind must submit fingerprints once in any 5-year period.

c. Officers and Board Members must submit fingerprints once in any 3 year period.

d. MEs will submit the most recent copies of each owner/officer/board member’s FingerprintSubmission Form and Background Check Waiver Form with the renewal application packet.Scan the form to a PDF document and name the file as follows:ME ID#_fingerprints_MM_YYYY.pdf.

Example: D001_fingerprints_03_2018.pdf.Burn this PDF document to the renewal application CD-R disk or thumb drive.

4. Submission of financial statements and audit reports is NO LONGER REQUIRED to renew MEregistration certificates.

5. Mail the renewal application CD-R or thumb drive to:

Department of TaxationMarijuana Enforcement Division.Attn: Marijuana License Renewal555 E. Washington Ave, #4100Las Vegas, NV 89101

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Entity Name:__________________ Establishment ID:_______ Tax Identification Number: (TID)_____________

ME ID # (i.e. D001, C050, etc.): _____________________________

ME License #: ___________________________________________

ME entity legal name filed with the Nevada Secretary of State (not DBA name):_________________________________________________________________________________________

ME physical address: ________________________________________________________________________________________________________________________________________________________________

ME local jurisdiction: _______________________________________________________________________

ME agent card designee (name of the person designated to submit applications for agent cards on behalf of theME): ____________________________________________________________________________________

For ME retail stores only – proposed hours of operation:_________________________________________________________________________________________

For ME testing facilities only:

Proof attached to application that the marijuana testing facility is accredited pursuant to ISO/IEC 17025 of theInternational Organization for Standardization. ☐ Yes ☐ No

Pursuant to R092-17 Sec.89(2)(d) A list and description of each of the following:

1. Has an owner, officer or board member of the ME been convicted of an excluded felony offense that has notpreviously been reported to the Department? ☐ Yes ☐ No

If yes, list the conviction(s) and date(s).______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Has an owner, officer or board member of the ME been issued a civil penalty or judgment that has notpreviously been reported to the Department? ☐ Yes ☐ No

If yes, list the civil penalty(s) or judgment(s) and the date(s) issued.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Has as an owner, officer or board member of the ME had the initiation of a federal, state or localgovernmental investigation or proceeding opened against them that has not previously been reported to theDepartment? ☐ Yes ☐ No

If yes, list the proceeding(s) or investigation(s) jurisdiction, case # and date(s).____________________________________________________________________________________________________________________________________________________________________________________

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Entity Name:__________________ Establishment ID:_______ Tax Identification Number: (TID)_____________

Pursuant to R092-17 Sec.89(2)(g) for each owner, officer and board member of this ME, identify whetherthat person:

4. Has served as an owner, officer or board member for an Medical ME or Recreational ME that has had itsregistration certificate or license revoked. ☐ Yes ☐ No

If yes, list the name of the person and the ME.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Is an attending provider of healthcare currently providing written documentation for the issuance of registryidentification cards. ☐ Yes ☐ No

If yes, list the name of the person.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Is a law enforcement officer. ☐ Yes ☐ No

If yes, list the name of the person and the law enforcement agency.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Is an employee or contractor of the Department. ☐Yes ☐ No

If yes, list the name of the person and the job title.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Entity Name:__________________ Establishment ID:_______ Tax Identification Number: (TID)_____________

8. The marijuana establishment agent card number(s) issued to each owner, officer or board member of themarijuana establishment:

9. Has an ownership or financial investment interest in any other ME. ☐ Yes ☐ NoIf yes, list the person, the other ME(s) and describe the interest.

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Name Agent Card No. Expiration Date

Name Other Marijuana Establishment ME ID# Interest Description

Entity Name:__________________ Establishment ID:_______ Tax Identification Number: (TID)_____________

ME Entity Name: ____________________________________________________ME ID # (i.e. D001, C050): _____________________________________Instructions: List all current owners, officers and board members for this ME. For owner entities other than natural persons, annotate the entity name (i.e. LLC or trust),and identify ALL natural persons in the entity, and their corresponding ownership interest percentage (%) in this ME. Use a continuation page if you need more space.

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Name Role(Owner,Officer,Board

Member)

Date of Birth (MM-DD-YYYY)

Physical Address Ownership% in this

ME

Total # of AgentCards issued to

this person

List all otherMEs for

which thisperson has been issued agent cards (List 4-digitME ID #s)

Entity Name:__________________ Establishment ID:_______ Tax Identification Number: (TID)_____________

ME contact name: _______________________________________________________________________

ME contact address: ____________________________________________________________________

ME contact phone: _____________________________________________________________________

ME contact email address: ________________________________________________________________

Attestation:

Pursuant to R092-17 Sec.89(2)(h), I attest the information provided to the Department to renew the ME’slicense is true and correct according to information known by the undersigned at the time of signing; and thesignature of a managing member or natural person for the ME as described in R092-17 Sec.74(1) and thedate on which he or she signed the application.

ME contact signature/date: _________________________________Date__________________

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