Registry of Intent to Modify Application

1
DCR Record Number* This field is required.DCR Application and Temporary License Numbers start with "LA-C" and Public Convenience or Necessity (PCN) Requests start with "LA-P"
2
Legal Entity Name
3
Name of Primary Contact* This field is required.
First Name
Last Name
4
Phone Number
Area Code
Phone Number
5
Email* This field is required.
example@example.com
6
What Type of Modification Request Do You Intend to Submit?* This field is required.Please select all that apply
Fictitious Business Name
Legal Entity Name Change
Business Premises Diagram
Business Premises Relocation
Ownership or Primary Changes
New Cannabis Activity
Other Contact Changes
Remove Cannabis Activity
7
Please describe your modification request
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: