Industrial Hemp Commercial/Research Authorization Application

Revised August 2009

1. Applicant Information

• Have you previously been authorized under the Industrial Hemp Regulations for crop sampling?
  • Yes
  • No
• Commercial Application
• Research Application
• File Number
  • 9636-8-
• Mr.
• Mrs.
• Ms.
• Miss.
• Surname
• Gender
  • Male
  • Female
• First Given name
• Second Given Name
• Date of Bir th (YYYY/MM/DD)
• Mailing Address
• City/Town
• Province
• Postal Code
• Telephone Number
• Fax Number
• Electronic Mail Address
• Preferred Language of Communication
  • Written:
    • English
    • French
  • Verbal:
    • English
    • French
• Preferred Method of Communication
  • Telephone
  • E-mail

2. Corporation, Cooperative, Partnership, or Research Institution Affiliation (if applicable)

• Registered Name
  • Corporation
  • Cooperative or Partnership
  • Research

3. Police Criminal Record Check

• Police Criminal Record Document
  • Original is attached
  • To be forwarded directly by Police by fax and/or mail
  • On file

4. Activity for which Authorization is Requested

• Crop sampling for THC test
• Seed sam pling for viability test
• Derivative sampling for THC test
• Possess, transport, send, or deliver industrial hemp
• Other (Please specify)

• I am
  • A Designated Agrologist
  • Recognized by the Canadian Seed Growers Association
  • Other
• Proof of above status is attached:
  • Yes
  • No (Please explain):
  • On file

5. Address of Location at which Activity will Take Place, or Samples will be Stored and/or Prepared

• All sample collection, preparation and sending to a laboratory will take place at currently licensed sites only, or
• Sample preparation and sending to a laboratory will take place at the following location:
  Legal de scription of the site (Concession , Lot , etc.):
  • Street Address
  • City/Town
  • Province
  • Postal Code

6. Briefly Describe Previous Crop Production and Sampling Experience

• (Attach separate sheet, if required)

7. Location at which Records will be Kept

• Same as mailing address, or
• Other (Please specify)

8. Consent for Publication of Name - Commercial Authorization Only

• I consent to the inclusion of my name, postal and e-mail addresses, telephone and facsimile numbers on a list to be published by Health Canada to inform cultivation licence holders of my authorization.
  • Yes
  • No
• Signature

9. Certification - All Applicants

• I hereby certify that I have read and understand the security measures, sampling and testing requirements under the Industrial Hemp Regulations and the Industrial Hemp Technical Manual and these requirements are met, or will be met before I commence any activity associated with any authorization issued to me. I further agree to comply with any terms and conditions as may be specified in any authorization issued to me.
  
  The information provided in this form is collected under provisions of the Privacy Act and you may be given access to, request correction of, or have a notation attached to information about yours elf. For more information, consult Info Source.
• Signature of Applicant
• Date

10. Certification of Researcher of Record Associated with Research Licences

• I hereby certify that I am the Researcher of record, I have read and understand the security measures and other requirements specified in the Narcotic Control Regulations. The specified requirements are met, or will be met before I commence any activity associated with any authorization issued to me. I further agree to comply with any terms and conditions as may be specified in any authorization issued to me. I understand that authorization under this application is limited to the research licence only, and is not valid for commercial purposes.
• Signature of Applicant
• Date

11. For Office Use Only

• Date Fax Received
• Date Original Received