Signature of Applicant Date

Printed Name of Applicant

IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, BY COLORADO LAW YOU CANNOT OBTAIN OR HOLD ACOLORADO MARIJUANA OCCUPATIONAL EMPLOYEE LICENSE.

I have thoroughly read and understand the questions above, and understand that I cannot hold a Colorado Marijuana license if at any timein the future I can ever answer “YES” to any of the questions above.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Have you served a sentence, including probation or parole, within the past 5 years upon conviction for any felony, evenif the conviction occurred more than 5 years ago?

Are you a licensed Physician making patient recommendations?

Have you had your authority to act as a primary caregiver revoked by the State Health Agency?

Are you under 21 years of age at the time of this application?

Are you the spouse or child living in the household of any person employed by the Colorado Marijuana Enforcement Division?

Are you a sheriff, deputy sheriff, police officer, or prosecuting officer, or an officer or employee of the marijuana statelicensing authority or a local licensing authority?

Colorado MED Minimum Requirements

If you answered YES to any of the above questions please stop and ask for assistance.

If you answered NO to ALL of the above questions and have a badge or have an appointment with the MED to apply for your badge,

please move on and complete the rest of the application.

If you do not have an occupational license through the MED, you must schedulean appointment with the MED before completing this application.

STOP

PAGE 1 OF 6

Yes No

Have you discharged a sentence for a conviction of a felony pursuant to any state or federal law regarding the possession, distribution, manufacturing, cultivation, or use of a controlled substance, including probation or parole, within the past 10 years, even if the conviction occured more than 10 years ago?

Applicants for employment must provide accurate and complete information on this Employment Application Form.Any false or misleading statements on this application will justify refusal of employment or, if employed by Pure Greens, termination of employment

These requirements can be found: www.colorado.gov/pacific/enforcement/marijuanaenforcement

Note: You must FIRST Download this PDF and Save it locally on your computer before filling it out!The application will NOT save your data if you fill it out from your web browser!

Application For EmploymentApplicants for employment must provide accurate and complete information on this Employment Application Form.Any false or misleading statements on this application will justify refusal of employment or, if employed by Pure Greens, termination of employment

PLEASE PRINT

DATE OF APPLICATION / /

LEGAL NAMELast First Middle Initial

ADDRESS (House Number & Street)

Have you ever been known by another name?

If yes, please list

Name Dates

Name Dates

City Zip

TELEPHONE

GENERAL

What position are you applying for? What salary are you seeking?

Are you able to work:

If part-time, please specify hours Date available to start employment

How did you hear about Pure Greens?

Have you ever applied for a position with Pure Greens? What action was taken on your application or what position(s) did you hold?

Do you have any relatives, including in-laws, that work at Pure Greens?

Do you have a valid Driver’s License?

If yes:

Name of Relative: Department: Relationship to you:

Alternative Email

( ) - ( ) -

Full-time

Advertisement Friend Employee Referral

Employee Name

Part-time Weekends

YES

YES

Please list any additional licenses held

YES NO

YES

Other

LICENSE

PERSONAL

Other Referral Source

PAGE 2 OF 6

NO

NO

NO

Do you have a valid Colorado Marijuana Occupational Employee License?

YES License number: Date of MED Appointment:NO / /

Application For EmploymentINITIALS OF APPLICANT

EMPLOYER CURRENT | MOST RECENT

Name

Supervisor’s name

Initial job title

Reason for leaving May we contact your current employer

Final / Current job title

Supervisor’s Telephone Employed From: /

To: /

Address Telephone

( ) -

( ) -

DATE OF APPLICATION / /

High School Name and Address:

GED State Issued:

Did you Graduate? Dates Attended Degree / Major

From /

Date Issued

/

To /

EDUCATION

EMPLOYMENT HISTORY

College Name and Address: Dates Attended Degree / Major

From /

To /

Graduate School Name and Address: Dates Attended Degree / Major

From /

To /

YES

NO

YES

YES

NO

YES

NO

YES

NO

YES

Present

Vocational or Technical School Name and Address:

Did you Graduate?

Did you Graduate?

Did you Graduate?

Did you Graduate? Dates Attended Degree / Major

From /

To /

Dates Attended

From /

To /

Other Courses or Special Training:

Please list extra-curricular activities, memberships in any academic organizations, or honors achieved that are associated with your educational history

List every employer (going back at least 3-5 years of your employment history), and list them in reverse chronological order, with your present or most recent employer first. All information may be verified including all months and years of employment.

PAGE 3 OF 6

NO

Application For Employment

PREVIOUS EMPLOYERName

Supervisor’s name

Initial job title

Reason for leaving

Final job title

Supervisor’s Telephone Employed

From: / To: /

Address Telephone

( ) -

( ) -

DATE OF APPLICATION / /

EMPLOYMENT HISTORY CONTINUED

PREVIOUS EMPLOYERName

Supervisor’s name

Initial job title

Reason for leaving

Final job title

Supervisor’s Telephone Employed

From: / To: /

Address Telephone

( ) -

( ) -

PREVIOUS EMPLOYERName

Supervisor’s name

Initial job title

Reason for leaving

Signature of Applicant Date

Final job title

Supervisor’s Telephone Employed

From: / To: /

Address Telephone

( ) -

( ) -

STATEMENT

The information provided in this application and in my resume (if supplied) is true and complete to the best of my knowledge. Any false or misleading statements in this application or in my resume will justify refusal of employment.

PAGE 4 OF 6

INITIALS OF APPLICANT

Application StatementPLEASE READ THE FOLLOWING CAREFULLY DATE OF APPLICATION / /

STATEMENT

PAGE 5 OF 6

The information provided in this application, in my resume (if supplied), and during my interview(s) is true and complete to the best of my knowledge. Any false or misleading statements in this application, in my resume, or in my interview(s) will justify refusal of employment or, if I am here after employed by Pure Greens, termination of employment.

Pure Greens may verify all of the information that I have provided on this application and I release Pure Greens and its representatives from liability for seeking such information and I release from all liability whatsoever any and all persons, institutions, business entities, and corporations providing Pure Greens such information. I further agree to sign whatever consent forms may be necessary to permit Pure Greens to verify all of the information that I have provided in this application.

I understand if I am o�ered employment I will be �ngerprinted and that such o�er and continued employment are conditional upon satisfactory clearance, which includes drug testing, satisfactory reference veri�cation, and other general information provided on this employment application. I understand that if I am o�ered employment, my employment will be “at will,” meaning that either I or Pure Greens may end the employment relationship for any lawful reason, at any time, with or without notice. In consideration of any employment which may be o�ered to me, I agree to comply with the policies, rules, regulations and procedures of Pure Greens.

This application will remain current for 180 days. At the conclusion of the 180 period, if I have not then been employed by Pure Greens, I understand that I must complete and submit a new application to remain eligible for consideration for employment.

Printed Name of Applicant

Signature of Applicant Date

I understand that in compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility veri�cation form upon hire.

Initials

Initials

Initials

Initials

Initials

Release AuthorizationPLEASE READ THE FOLLOWING CAREFULLY DATE OF APPLICATION / /

STATEMENT

PAGE 6 OF 6

The applicant for employment acknowledges and agrees that Pure Greens may now, or at any time while employed at Pure Greens, verify information within the application or resume for employment. In the event that the information from any report that Pure Greens obtains is utilized in whole or in part in making an adverse decision, before making the adverse decision, you will be provided with a copy of the report from the reporting agency.

Please be advised that we may also obtain an investigative consumer report including information as to your character, general reputation, personal characteristics, and mode of living. Pure Greens or a reporting agency may obtain this information by contacting your present and previous employers or references supplied by you. Please be advised that you have the right, upon written request to be informed whether such an investigative report was obtained and, if such report was obtained, you will be provided with the address of SAID REPORTING AGENCY, obtaining such reports to Pure Greens. You also have the right to request, in writing, within a reasonable time, that Pure Greens make a complete and accurate disclosure of the nature and scope of the investigation requested.

By signing below, I hereby authorize all entities having information about me, including present and former employers, personal references, criminal justice agencies, departments of motor vehicles, schools, and licensing agencies, to release such information to Pure Greens or any of its affiliates which will obtain this information on behalf of Pure Greens. I acknowledge and agree that if I am hired by Pure Greens this Release and Authorization shall remain valid and in effect during my period of employment with Pure Greens.

Printed Name of Applicant

Signature of Applicant Date

Initials

Initials