Authorized Agent Acknowledgment (Cannabis Regulation) {LIC-4009-FORM}

LIC-4009-FORM - AUTHORIZED AGENT ACKNOWLEDGEMENT. This form allows Applicants or Licensees to designate an Individual to sign and submit forms and documents to DCR on behalf of an Applicant or Licensee, including, but not limited to, modification, renewal, or amendment records, and communicate with DCR about the Application or License. The Authorized Agent must be one Individual who is also an Applicant’s or Licensee’s Primary Personnel, as defined in Los Angeles Municipal Code Section 104.01(a). Authorization shall expire based on the selection made in Part 1 of this form. Authorization may also be revoked at any time by completing Part 2 of this form. Please note: Authorized Agents will be granted access to information concerning the Application, License, and/or commercial cannabis business, including, but not limited to, personal identifying information, business records, and any records submitted as part of an application or renewal. Additionally, an Authorized Agent may also receive communications about the License or Application, including, but not limited to, notices concerning the Application or License status. www.FormsWorkflow.com