AFFIDAVIT1 NAME LAST FIRST MIDDLE2 DATE OF BIRTH4 AGENTS CURRENT CANNABIS LICENSE NUMBER eg 281282 2837 GIVEN SURNAMEBIRTH NAME if di erent from above 13 SOCIAL SECURITY NOIM ID: 885903
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1 AGENT: For license only. This form sh
AGENT: For license only. This form shall be used for all agent types including: Principal O cer, Agent-in-Charge and AFFIDAVIT 1. NAME LAST FIRST MIDDLE2. DATE OF BIRTH 4. AGENTS CURRENT CANNABIS LICENSE NUMBER (e.g. 281,282, 283)7. GIVEN SURNAME/BIRTH NAME (if di erent from above #1) 3. SOCIAL SECURITY NO.IMPORTANT NOTICE: In lieu of providing and ngerprint-based background in Part 1290 Rules for Administration of the a) There has NOT been a change in my criminal record since my last ngerprint submission to the IDFPR; orb) There has been a change in my criminal record since my last ngerprint submission and I reported the change to IDFPR; andc) If I am convicted of an o ense subsequent to the submission of this a davit, I will report the conviction to IDFPR with my name, license number, the criminal charge(s), case number and the prosecuting county promptly, within 24 hours, of the conviction through ema IL486-2416 2/21 6. ADDRESS CITY STATE/COUNTRY ZIP CODE Signature of Licensed Agent Date Signature of Notary Date Seal 5. AGENTS REGISTERED DISPENSARY NAME AND LICENSE NO. 280.