DRUG-1                                             APPLICATION FOR 
   REV 02-19                          DRUG PARAPHERNALIA LICENSE 
                                                                                      (Code 47-19) 
Complete this form for each location. 
                                      SECTION A: REASON FOR SUBMITTING THIS APPLICATION 
                                                                                                   NUMBER  OF  EMPLOYEES  AT  THIS  LOCATION 
 CHOOSE ONLY ONE:       SUBMITTED WITH BUS-APP        SUBMITTED WITH BUS-RBL                       Attach Drug Paraphernalia Affi  davits for each employee 
                                                                                                   selling paraphernalia from this location
                                                      SECTION B: BUSINESS IDENTIFICATION 
   LEGAL BUSINESS NAME                                                                             FEIN (SSN For Sole Proprietor) 

 1 DBA (Complete Schedule DBA for each additional DBA)

   PHYSICAL ADDRESS OF BUSINESS NAMED ABOVE No Post Offi  ce Boxes

 2
   CITY                                                                                            STATE                                     ZIP

   MAILING ADDRESS

 3
   CITY                                                                                            STATE                                     ZIP

                                                      DESCRIPTION OF BUSINESS                                                                BUSINESS PHONE NUMBER

                                      SECTION C: APPLICANT INFORMATION (required)
                                      NAME OF APPLICANT                                                  APPLICANT SSN                       DATE OF BIRTH (MMDDYYYY)

 I, the undersigned, swear that I have never been convicted of a drug-related off ense.

 SIGNATURE OF APPLICANT                                                                            DATE

         TAKEN, SUBSCRIBED, ACKNOWLEDGED AND 
              SWORN TO BEFORE ME ON THIS DATE :

                       MY COMMISSION EXPIRES ON:

                                      NOTARY PUBLIC                                                                                        (NOTARY SEAL)

                                                                                                         AMOUNT DUE                          $    150.00

                                                                                                   *B28201901W*
                                                                                                   B 2   8 2 0                             1 9 0          1 W