Documentation of Property Ownership To be completed by the owner of the physical address of the proposed medical marijuana establishment

Name of Individual or Entity Applying for Establishment:

Name of Owner of the Physical Address of the Proposed Establishment:

Physical Address of Proposed Dispensary:

City:

County:

State:

Zip Code:

Legal Description of the Property:

The Individual or entity applying for the establishment is the owner of the physical address of the proposed establishment. OR

The owner of the physical address of the proposed establishment gives permission to the individual or entity applying for an establishment to operate at the physical address.

Property Owner Name

Title

Property Owner Signature

Date Signed

Notary Public SUBSCRIBED AND SWORN TO BEFORE ME THIS

DAY OF

BY

AS THE OWNER/APPLICANT

NOTARY PUBLIC

MY COMMISSION EXPIRES

Planning and Environmental Resources 10 E. Mesquite Blvd., Mesquite, NV 89027 Phone (702) 346-2835, FAX (702) 346-5382, www.mesquitenv.gov

08/14

Form - Planning - Medical Marijuana Owner Authorization.pdf ...

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