FINANCIAL INFORMATION FORM

BCC-LIC-013 (Rev. 12/17) California Department of Consumer Affairs

Bureau of Cannabis Control bcc.

State of California Gavin Newsom, Governor

FINANCIAL INFORMATION FORM

Instructions: You must complete every section on the form for each item that is listed. Forms that are incomplete will be returned.

FINANCIAL HISTORY - Attach additional copies if needed

Section A - List all investments made into the applicant's commercial cannabis business

1. Name of Investor

Address

Phone Number

Term(s) of Investment 2. Name of Investor

Address

Date of Investment

Amount

$

Phone Number

Term(s) of Investment 3. Name of Investor

Address

Date of Investment

Amount

$

Phone Number

Term(s) of Investment 4. Name of Investor

Address

Date of Investment

Amount

$

Phone Number

Term(s) of Investment

SECTION B - List all loans made to the applicant's commercial cannabis business

1. Name of Lender

Address

Date of Investment

Amount $

Phone Number

Term(s) of Loan 2. Name of Lender

Address

Security Provided For Loan

Date of Loan

Amount $ Phone Number

Term(s) of Loan 3. Name of Lender

Address

Security Provided For Loan

Date of Loan

Amount $ Phone Number

Term(s) of Loan

Security Provided For Loan

Date of Loan

Amount

$

SECTION C - List all funds belonging to the applicant Financial Institution Name Address

Account Type

Account Number

Amount

$

Financial Institution Name Address

Account Type

Account Number

Amount

$

Financial Institution Name Address

Account Type

Account Number

Amount

$

Financial Institution Name Address

Account Type

Account Number

Amount

$

SECTION D - List all gifts of any kind given to the applicant for use in conducting commercial cannabis activity

Name of Provider

Address

Phone Number

Value/Description of Gift

Name of Provider

Address

Phone Number

Value/Description of Gift

Name of Provider

Address

Phone Number

Value/Description of Gift

BCC-LIC-013 (Rev. 12/17)

Page 1 of 1

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download