Except as provided in R9-17-107(F), to obtain a dispensary agent registry identification card for an individual serving as a principal officer or board member for the dispensary, employed by or contracted with the dispensary, or providing volunteer services at or on behalf of the dispensary, the dispensary shall submit to the Department the following for each dispensary agent:

1. An application in a Department-provided format that includes:

a. The dispensary agent’s first name; middle initial, if applicable; last name; and suffix, if applicable;

b. The dispensary agent’s residence address and mailing address;

c. The county where the dispensary agent resides;

d. The dispensary agent’s date of birth;

e. The identifying number on the applicable card or document in subsection (5)(a) through (5)(e);

f. The name and registry identification number of the dispensary; and

g. The signature of the individual in R9-17-304(D)(1)(d) designated to submit dispensary agent’s applications on the dispensary’s behalf and the date the individual signed;

2. An attestation signed and dated by the dispensary agent that the dispensary agent has not been convicted of an excluded felony offense as defined in A.R.S. § 36-2801;

3. One of the following:

a. A statement that the dispensary agent does not currently hold a valid registry identification card, or

b. The assigned registry identification number for the dispensary agent for each valid registry identification card currently held by the dispensary agent;

4. A statement in a Department-provided format signed by the dispensary agent pledging not to divert marijuana to any individual or entity who is not allowed to possess marijuana pursuant to A.R.S. Title 36, Chapter 28.1;

5. A copy of the dispensary agent’s:

a Arizona driver’s license issued on or after October 1, 1996;

b. Arizona identification card issued on or after October 1, 1996;

c. Arizona registry identification card;

d. Photograph page in the dispensary agent’s U.S. passport; or

e. Arizona driver’s license or identification card issued before October 1, 1996 and one of the following for the dispensary agent:

i. Birth certificate verifying U.S. citizenship,

ii. U. S. Certificate of Naturalization, or

iii. U. S. Certificate of Citizenship;

6. A current photograph of the dispensary agent;

7. For the Department’s criminal records check authorized in A.R.S. § 36-2804.05:

a. The dispensary agent’s fingerprints on a fingerprint card that includes:

i. The dispensary agent’s first name; middle initial, if applicable; and last name;

ii. The dispensary agent’s signature;

iii. If different from the dispensary agent, the signature of the individual physically rolling the dispensary agent’s fingerprints;

iv. The dispensary agent’s address;

v. If applicable, the dispensary agent’s surname before marriage and any names previously used by the dispensary agent;

vi. The dispensary agent’s date of birth;

vii. The dispensary agent’s social security number;

viii. The dispensary agent’s citizenship status;

ix. The dispensary agent’s gender;

x. The dispensary agent’s race;

xi. The dispensary agent’s height;

xii. The dispensary agent’s weight;

xiii. The dispensary agent’s hair color;

xiv. The dispensary agent’s eye color; and

xv. The dispensary agent’s place of birth; or

b. If the dispensary agent’s fingerprints and information required in subsection (8)(a) were submitted to the Department within the previous six months as part of an application for a designated caregiver registry identification card or a dispensary agent registry identification card for another dispensary, the registry identification number on the registry identification card issued to the dispensary agent as a result of the application; and

8. The applicable fee in R9-17-102 for applying for a dispensary agent registry identification card.

This is an unofficial version of the Medical Marijuana Program rules. At this time, ADHS does not anticipate making substantive changes to these rules before they are filed with the Office of the Secretary of State. However, technical, organizational, and grammatical changes may be made. The official copy will be posted on www.azsos.gov when filed.