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
SECTION C - DECLARATIONS
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
Gavin Newsom, Governor
DCC-LIC-007 (Rev. 3/22) Page 1 of 4
17. Name
Email Ownership % Title
Mailing Address City State Zip Code
Social Security Number
Date and Place of Birth
Government-Issued Identification Number
18. Name of Entity
Organizational Structure
Phone Number
Email Address
19. Name Date of Birth
Government ID Type Government ID Number
20. Business Name
Address City State Zip Code
Business Name
Address City State Zip Code
SECTION H - LICENSING FEE DETERMINATION
Identify the appropriate tier category in which your expected gross revenue for the 12-month license period belongs as provided in
Department Regulations section 15014 listed below.
Distributor Type 11 & Distributor-Transport Only Type 13
Less than or equal to $1 million ($1,500) More than $1 million and less or equal to $2.5 million ($6,000)
More than $2.5 million and less or equal to $5 million ($11,250) More than $5 million and less or equal to $10 million ($22,500)
More than $10 million and less or equal to $20 million ($45,000) More than $20 million and less or equal to $30 million ($75,000)
More than $30 million and less or equal to $50 million ($120,000) More than $50 million and less or equal to $70 million ($180,000)
More than $70 million ($240,000)
Distributor-Transport Only Self-Distribution Type 13 (If answered "Yes" to question 16)
Less than or equal to $1,000 ($200) More than $1,000 and less or equal to $3,000 ($500)
More than $3,000 ($1,000)
Telephone Number
Current Employer
Name of Primary Contact
Ownership %
SECTION D - LIST OF OWNERS
An owner is defined as a person with an aggregate ownership interest of 20% or more, chief executive officer,
member of the board of directors of a nonprofit, or an individual participating in the direction, control, or management of the applicant. All business
owners must be listed, including yourself. Attach additional pages if needed. Each owner is required to submit an Owner Submittal form.
SECTION F - NON-OWNERS WITH A FINANCIAL INTEREST IN THE BUSINESS (attach additional pages if needed)
SECTION G - FICTITIOUS BUSINESS NAMES
SECTION E - ENTITY FINANCIAL INTEREST HOLDERS An entity is anything other than an individual. If an entity is a financial
interest holder of the commercial cannabis business pursuant to Business and Professions Code section 26001(al), you will need to
complete the following information. Attach additional pages if needed.
DCC-LIC-007 (Rev. 3/22) Page 2 of 4
Evidence of legal right to occupy and use the proposed premises location.
Premises Diagram Form
If the business is a foregin corporation or foreign LLC: a certificate of qualification, registration, or status issued by the
California Secretary of State.
Evidence of premises compliance with local jurisdiction, if answered "Yes" to question 9.
Limited sovereign immunity waiver, if answered "Yes" to question 10.
Evidence of exemption from, or compliance with, the California Environmental Quality Act.
Labor peace agreement documentation, related to question 14.
Proof of surety bond in the amount of $5,000, payable to the State of California.
License Type: Date of Denial, Suspension, or Revocation:
Licensing Authority:
Signature Printed Name Date Signed
Office Use Only - CLEaR Application Record Number:
DISCLOSURE OF LICENSE HISTORY If you have previously been denied a license or had a license suspended or revoked by the
Department or any other state cannabis licensing authority, provide the type of license denied, suspended, or revoked, the name of the
licensing authority, and the date of the denial, suspension, or revocation.
Under penalty of perjury, I hereby declare that the information contained within and submitted with this application is
complete, true, and accurate. I understand that a misrepresentation of fact is cause for rejection of this application, denial of a
license, or revocation of a license issued.
See Disclosures on the Next Page
SECTION I - REQUIRED ATTACHMENTS/DOCUMENTS
AFFIRMATION AND CONSENT
DCC-LIC-007 (Rev. 3/22) Page 3 of 4