AFFIDAVIT STATE OF COUNTY OF Personally came and appeared

Affidavit of Applicant

Mississippi Medical Cannabis Act 1 of 3

AFFIDAVIT

STATE OF _____________________________

COUNTY OF ___________________________

Personally came and appeared before me, the undersigned Notary, the within named

____________________________, who is a resident of ________________ County, State of

____________________________, who having been duly sworn, stated upon oath and under

penalty of perjury, the following:

I am an applicant as defined under the Mississippi Medical Cannabis Act. I declare under

penalty of perjury that I have not been the subject of a conviction for a disqualifying felony offense.

Disqualifying felony offense means:

(i) A conviction for a crime of violence as defined by Miss. Code Ann. §97-3-2. (97-

3-2 is attached.)

(ii) A conviction for a crime that was defined as a violent crime in the law of the

jurisdiction in which the offense was committed, and that was classified as a felony

in the jurisdiction where the person was convicted; or

(iii) A conviction for a violation of a state or federal controlled substances law that was

classified as a felony in the jurisdiction where the person was convicted, including

the service of any term of probation, incarceration or supervised release within the

previous five (5) years and the offender has not committed another similar offense

since the conviction. Under this subparagraph (iii), a disqualifying felony offense

shall not include a conviction that consisted of conduct for which this chapter would

likely have prevented the conviction but for the fact that the conduct occurred

before the effective date of this act.

RESET

Affidavit of Applicant

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I understand and acknowledge that I am not eligible to receive a medical cannabis business

license if I have been convicted of a disqualifying felony offense.

Choose one [1]:

□ I further certify that I have not been the subject of: (i) a warrant for arrest; (ii) an

arrest; or (iii) a pending diversion agreement for a disqualifying felony offense.

□ I further certify that I have been the subject of: (i) a warrant for arrest; (ii) an arrest

or (iii) a pending diversion agreement for a disqualifying felony offense, as follows

[please explain in the space below]:

________________________________________________________________________

I understand and acknowledge that the State of Mississippi will be conducting a

background check to determine whether I have been convicted of a disqualifying felony. To

complete a background check, I understand and acknowledge that my information, including

fingerprints, will be transmitted through the applicable federal and state databases. I understand

and agree that results of my background check showing that I have been convicted of a

disqualifying felony will constitute a basis for revocation or denial of any applicable medical

cannabis business license.

I understand that a license issued under the Mississippi Medical Cannabis Act is not a

property right, and as such is revocable.

I agree, to the fullest extent allowed by law, to indemnify, defend, save and hold harmless,

protect, and exonerate the Governor of the State of Mississippi, the Mississippi Department of

Public Safety, the Mississippi Department of Health, the Mississippi Department of Revenue, their

commissioners, executive directors, board members, officers, employees, agents, and

Affidavit of Applicant

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representatives, and the State of Mississippi, from and against all claims, demands, liabilities, suits,

actions, damages, losses, and costs of every kind and nature whatsoever including, without

limitation, legal costs, investigative fees and expenses, and attorney’s fees, arising out of the denial

or revocation of a medical cannabis business license based on any disqualifying felony of which I

may have been convicted.

DATED this the _______________ day of ______________________, 20______.

__________________________________________

Signature of Affiant

SWORN to and subscribed before me, this the ______ day of __________________, 20______.

__________________________________________

NOTARY PUBLIC