Colorado Department of Revenue Medical Marijuana Enforcement Division

Forms Packet June 16, 2011

This Packet contains information and forms to give Applicants guidance necessary for compliance 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 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. In regard to the Travel Manifest form you must use the form provided and it must be sent to our office for approval 24-hours (during the work week, be sure to accommodate weekends and holidays in this calculation) prior to the actual transportation of the product takes place. The form may be sent to our office via fax (send to fax number 303-205-2398 or via email at MMEDmanifest@dor.state.co.us 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 licenses prior to submittal of this list enter pending on the License Number column. All centers should also submit your patient list which must be complete as to reflect your Centers paperwork. This 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. Forms may be faxed to 303-205-2398 or Mailed to our offices at: MMED Form Submission 455 Sherman Street, Suite 390, Denver, CO 80202

MMED investigators will soon begin visiting Medical Marijuana Centers (MMCs), Optional Premise Cultivations (OPCs) and Marijuana Infused Product (MIPs) 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 nonprimary 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 Division Medical Marijuana Transportation Manifest

All sales transactions are to be completed prior to transportation of any Medical Marijuana, receiving Center may reject product delivered, but amount delivered must be limited to amount agreed upon in prior sales transaction. Fax form to 303-205- 2398 or email to MMEDmanifest@dor.state.co.us Date Completed: Name of Originating Entity: Location of Originating Entity: License Number 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 Route to be traveled:

Date and Approximate Time of Arrival

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 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 Secure Facility Form

All Medical Marijuana Businesses operating with the State of Colorado must install security/video surveillance systems in each business location. Attached system lay-out to this form. Submit Form to: Date Submitted: Business Name : Physical Address: License Number

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 DIVISION 70 / 30 COMPLIANCE CHECK REPORT For the 12 Months Ending (add month and year)

Licensee Name: Licensee Number: Jan Beginning Inventory On-Hand in Grams Increases Transfers from Grow Wholesale Purchases Adjustments (attach explanation) Subtotal Increases Total Gross Inventory On-Hand in Grams Decreases Sales to Patients Wholesale Sales Adjustments (attach explanation) Subtotal Transfer to MIPS
(100% for nonsmokables)

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

YTD

(A)

(B) (C)

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 sales 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

MMD form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION MONTHLY REPORTING EMPLOYEE LIST

Licensee Name Licensee Number

Date Reporting Month

Number

Employee License #

Employee Address Employee Last Name Employee First Name Street Address City Zip

Must Choose New or Status Change Status Change New (Name,

License #, Terminated)

Effective Date

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

Signature

Date

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION CHANGE IN EMPLOYEE STATUS

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:

Business Name

License Number

Date

Employee License Number

Employee Last Name

Employee First Name

Employee Address Street Address City Zip

Change of Status
Name Change Please List New Information Below: Address Change Employee License Number Change

Terminated Employment Please explain:

Other

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.

Signature

Date

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION PRIMARY CENTER PATIENT LIST

Date
Licensee Name Licensee Number

Reporting Month

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

Number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Patient ID Number

Patient Card Expiration Date

Maximum Primary Center Designation Plants Per Date Patient *

Total Plant Count

* For each patient with a plant count greater than 6, additional documentation is 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

Signature

Title

Date

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION PATIENT STATUS CHANGE 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:

Date

Effective Date

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

Patient ID Number

Patient Card Expiration Date

Primary Center Designation Date

Status Change
(e.g. ID #, plant limit, Primary Center designation)

# of Plants for this Patient

Please Explain Status Change Below:

* For each patient with a plant count greater than 6, additional documentation is 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

Signature

Title

Date

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION WHOLESALE SALES REPORT Daily Summary

Daily Wholesale Sales Report

Day Licensee Name and # Weight Quantity Unit Price Total Extended (in grams) in grams Price Employee ID #

Transaction # 1 2 3 4 5 6 7 etc Daily Totals

Licensee Name
(Recipient)

Licensee Number
(Recipient)

Strain

Product Description Batch #

na

na

na

na

na

0.00

na

na

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

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION PATIENT SALES REPORT Daily Summary

Daily Patient Sales Report

Licensee Name and # Weight Quantity

Transaction #

Patient ID #

Strain

Batch #

Product Description

Total Extended (in grams) Unit Price Price Employee ID #

1 2 3 4 5 6 7 etc Daily Totals na na na na 0.00 na $ na

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

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION SALES SUMMARY REPORT Monthly

Monthly Sales Report

Month: Licensee Name and #

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Monthly Totals

Daily Patient Sales (in grams)

Daily Wholesales (in grams)

Totals 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00

0.00

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

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION WHOLESALE PURCHASES REPORT Daily Summary

Daily Wholesale Purchases Report

Day: Purchased from Licensee Name Purchased from Licensee Number

Licensee Name and #

Transaction # 1 2 3 4 5 6 7 etc Daily Totals

Strain

Product Description

Batch #

Weight Quantity Total Extended (in grams) Unit Price Price Employee ID #

na

na

na

na

na

0.00

na

na

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

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

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION TRANSFERS 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)

Employee Initials

Employee ID # (Center or MIP)

Employee Initials

Total

na

na

0.00

na

na

na

na

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

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

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION TRANSFERS FROM GROW and PURCHASES Monthly

Monthly Transfers from Grow and Wholesale Purchases

Month: Wholesale Purchases (in grams) Licensee Name and # Transfers from OPC (in grams)

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Monthly Total

Totals 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00

0.00

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

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

S:\Audit\Forms\Daily-Montlhly Purchases Report _MT.xlsMonthly Purchases-Transfers

MMED form rev 7/2011

MEDICAL MARIJUANA ENFORCEMENT DIVISION WHOLESALE TRANSACTION FORM Sales

Licensee Name Licensee Number Date of Transaction Prenumbered

Sold to:
MMC or MIP Name MMC or MIP License Number

Strain

Product Description

Batch #

Weight Quantity (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

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

Print Name and Title (Licensee)

Print Name and Title (MIP or MMC)

Signature and Date

Signature and Date

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 DIVISION WHOLESALE TRANSACTION FORM Purchases

Licensee Name Licensee Number Date of Transaction Prenumbered

Purchase from:
MMC or MIP Name MMC or MIP License Number

Strain

Product Description

Batch #

Weight Quantity (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

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

Print Name and Title (Licensee)

Print Name and Title (MIP or MMC)

Signature and Date

Signature and Date

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

MMED Rev 7/2011