Ownership And Financial Interest Holder Form (Cannabis Regulation) {LIC-4008-FORM}

LIC-4008-FORM - LEGAL BUSINESS ENTITY RECORD DISCLOSURE FORM. Applicants shall disclose all ownership, primary personnel, and financial interest holder information as instructed below. Please provide the names and titles/roles of all Primary Personnel and Owners associated with the Applicant Entity seeking licensure. Check the applicable box(es) to identify if the Person is a Primary Personnel, Owner, Indirect Owner or Financial Interest Holder. Please attach additional pages if necessary and number accordingly. In addition, please attach a chart(s), using the format below, that discloses the ownership of the Applicant until only individuals remain. Please note that providing false or misleading information, or failing to disclose a material fact, may be grounds for denial of the license application. Additionally, if after licensure, DCR determines that a Licensee provided false or misleading information, or omitted material facts, DCR may suspend or revoke the License, or take other administrative action permitted by law. Please review all definitions contained in this form and instructions. Any terms not defined herein shall have the meanings set forth in Los Angeles Municipal Code (LAMC) Section 104.01. For example, “individual” means a natural person as defined in LAMC Section 104.01(a)(26). www.FormsWorkflow.com