1. License Type Designation (Please check ALL that apply):
Adult-Use (A-license) Medicinal (M-license)
2. License Type (Please check ONE):
Distributor (Type 11) Distributor - Transport Only (Type 13)
3. Business Organizational Structure (Please check ONE)
Sole Proprietorship Limited Liability Company General Partnership
Corporation (or foreign corporation) Limited Partnership Limited Liability Partnership
4. Name (sole proprietor first and last, all other business types legal business name) Doing Business As (DBA)
5. Business Premises Address City State Zip Code
Mailing Address (if different from premises address) City State Zip Code
6. Business Website Business Email Address Business Phone Number
7. Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN); or Business's Federal Employer Identification Number (FEIN)
8. Name Title Phone Number Email Address
9. Is the proposed premises located within a 600-foot radius of a school (K-12), day care center, or youth center? Yes No
10. Are you a federally recognized tribe or other sovereign entity? Yes No
11. Do you have evidence of California Environmental Quality Act (CEQA) compliance or exemption? Yes No
Seller's Permit Number, if applicable. are currently applying for one? Yes No
Identification Number (SEIN).
14. If your company has 20 or more employees (not including supervisors) for the cannabis business, please select one of the following:
I will provide a notarized statement with this application that the commercial cannabis business will enter into and abide by Yes
the terms of a labor peace agreement.
I will provide documentation with this application that demonstrates that the commercial cannabis business has already
entered into and will abide by the terms of the labor peace agreement. Yes
If your company has less than 20 employees (not including supervisors), you must attach a notarized statement indicating that you
will enter into and abide by a labor peace agreement within 60 days of hiring your 20th non-supervisory employee.
15. If your company has one or more employees (not including supervisors) do you attest that you have or will have within one year
of licensing, one supervisor and one employee that have completed a Cal-Osha 30-hr general industry course offered and provided by
You have entered into a labor peace agreement and have attached a copy of the signature page of the agreement
an OSHA Training Institute Education Center? Yes
16. Will you be transporting only cannabis goods that you have cultivated or manufactured? Yes No
If yes, provide your manufacturing or cultivation license number(s)
CANNABIS DISTRIBUTOR LICENSE APPLICATION
APPLICATION FEE $1000 (NON-REFUNDABLE)
SECTION A - APPLICANT/BUSINESS INFORMATION Please provide the below business information for your cannabis license.
SECTION B - PRIMARY CONTACT PERSON This will be the contact for any questions regarding this application and the Department
staff will only be able to discuss the application with this person or an owner of the business. If you have an agent for service of process
that is different than the primary contact or designated responsible party, please include their contact information below.
13. Number of employees? (not counting owners) If more than 1 employee, provide State Employment
To pay the application fee by cash, contact the Department to schedule an appointment.
12. Applicant's California Department of Tax and Fee Administration If no Seller's Permit, do you attest that you (applicant)
DCC-LIC-007 (Rev. 3/2022)
Department of Cannabis Control
www.cannabis.ca.gov
State of California
DCC-LIC-007 (Rev. 3/22) Page 1 of 4