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(2) The name., mailing address. and telephone number of the applicant, <br />_ (3) The cooperative or collective name and street address for which registration is sought, as <br />well s anv other names under which the collective or cooperative may operate- <br />(4) Copies of the collective or cooperative's entity-formation document such as_ without <br />lino , its Articles of Incorpra io Articles of Association, LC Operati g or <br />cetera. <br />C5) A one page description of the collect' perative's nature and its plans for security <br />and non-diversion of medical cannabis. <br />(¢) The following information concerning each director, officer, or senior general manager of <br />the collective or cooperative: <br />(A) Complete legal name and any alias( <br />(B) Date of birth: <br />( A copy _of?d government-issued hoto identification car or license: <br />(E) A list of any felony convictions fora y?rimes of violence, larceny. or fraud within <br />the =previous 10 years, which shal be gro nds for disqualification as shall failure to <br />disclose. <br />(7) Documentation that the collective or cooperative is located in a C1, C4, C5._Ml.p_or C- <br />SM use district of the Cily where they are neither authorized nor prohibited, and that it is <br />located at least 600 feet from any school as defined herein Medical cannabis collectives_ <br />and co eratives are prohibited i all other use districts in the City including in <br />residential use districts: RE, RI, R2- R3, R4, and CR. <br />(8) Some form of dated documentary evidence that the collective or cooperative had begun <br />op re a6ng at the location prior to December 31, 2011, including but not limited to, a lease <br />a utility receipt, a State Boar of Equalization Seller's Permit, o a Federal Eml2lUer <br />Ide tiAcatio Number. <br />(9) A dated statement signed by an individual member authorized to represent and legally <br />bin the collective or cooperative , certifying undcLnenalty of perky that the information <br />provided in the registration form and any atta hment thereto is true, complete, and <br />correct. <br />65A-15