This is the exact embedded text of the captured official document.
Snapshot 0134f124b1a4 · verified 2026-06-08 ·
original document ·
archived snapshot ·
unofficial consolidation, the official version is held by the municipal clerk.
Applicant Disclosure - Cannabis
Page 1
RESTRICTED WHEN COMPLETED
Town of Fox Creek
Applicant Disclosure - Cannabis Retailer
Read the instructions carefully - they contain important information required for the completion of the
disclosure package.
Cannabis Retail Applications may be submitted to the Town by the following means
In-Person:
Town Administration Office
Planning and Development (Development Permitting)
102 Kaybob Drive
Fox Creek, Alberta T0H 1P0
Electronic Submissions via:
Email: [email protected]
Subject line: Cannabis Retail Application
Mail Submissions via:
Town of Fox Creek
Attn: Director of Planning and Development (Business Licensing)
PO Box 1410
Fox Creek, Alberta T0H 1P0
For further information, please contact the Director of Planning and Development by telephone at
780.622.3896 or by email at [email protected].
Applicant Disclosure - Cannabis
Page 2
RESTRICTED WHEN COMPLETED
INSTRUCTIONS
A. TERMS / DEFINITIONS
1.
AGLC - Alberta Gaming, Liquor & Cannabis
2.
Applicant - Individual, corporation or other
entity applying for a license, registration or
approval.
3.
Associated Applicant - Individual, corporation
or other entity that is or will be in a(n):
I.
Owner;
II.
Partner (in a partnership);
III.
Promoter;
IV.
Shareholder directly or indirectly
controlling 10% or more of the shares in
the Applicant; or
V.
Any Individual or entity with a direct or
indirect financial interest of 10% or more
in the Applicant.
4.
Cannabis License - means a license under
the Gaming, Liquor and Cannabis Act (Alberta)
that authorizes the purchase, sale, transport,
possession, storage or use of cannabis.
5.
Cannabis Supplier - means a person who
holds a license under the Federal Act that
authorizes the person to produce cannabis for
commercial purposes or to sell cannabis to
AGLC.
6.
Control -
I.
Power to direct;
II.
Any direct or indirect influence which, if
exercised, would result in control in fact
of the corporation whether directly
through the ownership structure, or
indirectly through a trust, a contract,
ownership of shares, stocks, equities or
securities of another corporation or
entity.
III.
The ability to appoint, elect or cause the
appointment or election of a director,
whether or not that ability is exercised.
IV.
Any owner, shareholder, other
individual, or corporate entity related to
an associated applicant that has direct
or indirect control of 10% or more of the
applicant.
7.
Controlling Interest - The holding by an
individual group or corporate entity a majority of
a business, giving the holder a means of
exercising control.
8.
Director -
I.
Those individuals acting collectively to whom the
duty of managing the general affairs of the
company is delegated by the shareholders. Their
duty is to conduct the business of the company for
the greatest benefit of the shareholders.
II.
Any individual acting in a capacity of the Town
similar to that of a director of a company.
III.
A trustee, officer, member of an executive
committee and any individual occupying a similar
position.
9.
License and/or registration - a license or registration
issued under the Gaming, Liquor and Cannabis Act.
10. Officer -
I.
An individual employed in connection with the
administration and management of a department.
II.
The chairman and vice-chairman of the board of
directors, the president, vice-president, secretary,
assistant secretary, treasurer, assistant treasurer,
general manager, and any other individual
designated an officer by by-law or resolution of the
directors, and any other individual who performs
functions for a company similar to those normally
performed by an individual occupying any of those
offices.
III.
The chairman, president, vice-president, secretary,
treasurer, comptroller, general counsel, general
manager, director, managing director or any other
individual who performs functions for a corporation
similar to those normally performed by an individual
occupying any such office.
11. Partner - A reference to a partner of an individual
includes a spouse, common-law spouse or individual
connected to the applicant by virtue of an adult
interdependent relationship.
12. Promoter - Any individual, corporation or other entity
who:
I.
Acting alone or in concert with one or more
individuals or corporate entities, directly or
indirectly takes the initiative in founding,
organizing or substantially reorganizing a
business, or
INSTRUCTIONS - CONTINUED
Applicant Disclosure - Cannabis
Page 3
RESTRICTED WHEN COMPLETED
II.
In connection with the founding,
organization or substantial
reorganization of the business, directly
or indirectly received, in consideration of
services or property or both, 10% or
more of a class of shares of 10% or
more of the proceeds from the same of a
class of shares.
B. COMPLETING THE DISCLOSURE
1.
Individuals are only required to complete one
disclosure form.
2.
Enforcement Services may request disclosure
from other individuals and entities associated
with the applicant.
3.
An answer must be provided for every question
- do not leave blank spaces:
I.
If a question does not apply, write "Does
not Apply" or "N/A".
II.
If there is nothing to disclose, write
"None'
III.
Answers such as see previous
disclosure or no changes since last
disclosure are NOT acceptable when
questions ask for current information.
4.
All disclosures must be typed or printed clearly.
Illegible disclosures will be returned.
5.
The disclosure may not be modified in any way.
Modified disclosures will be returned.
6.
If additional space is required, either make
additional copies of the page, or use additional
paper and attach it to the appropriate page.
7.
All attachments must be clearly labelled as
"Attachment 1, Attachment 2, Attachment 3,"
etc. The attachment number must then be
noted in the space provided beside the
applicable question.
8.
All attachments must be an accurate copy of
the original, and be signed by you.
9.
The disclosure must be signed/initialed as
follows:
I.
Initial and date each page to verify all
statements made are accurate, all
material facts are included, and all
requested information and documents
are provided.
II.
Sign the Statutory Declaration. The
Declaration must be witnessed by an
individual authorized to take
declarations.
10. Keep a copy of the disclosure for your records.
You may be contacted for further information,
documents or clarification.
11. Incomplete disclosures will be returned to the
appropriate individual for completion.
C. IMPORTANT INFORMATION
1. All information and documents provided as part
of this disclosure:
I.
Become Property of Enforcement
Services and will not be returned.
II.
Are confidential and will be treated as
such.
III.
Are for Enforcement Services use to
determine the applicant's eligibility for a
business license.
IV.
Will be verified through an investigative
process - further information,
documents or clarification may be
requested.
D. PROTECTION OF INFORMATION
1. The information collected in this disclosure is
only used in determining the eligibility of the
applicant for a business license.
2. All application packages shall be kept
confidential and shall only be released in
accordance with the Freedom or Information
and Protection of Privacy Act (FOIP Act)
(Alberta)
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 4
APPLICANT IDENTITY
1. Applicant's Legal Name:
2. Retailer Name:
3. Business Address:
Street:
Town:
Province:
Country:
Postal Code:
Website:
4. Mailing Address:
Street/ Box:
Town:
Province:
Country:
Postal Code:
5. Company Representative to contact regarding all matters
Name:
Position:
Birth Date:
Mailing Address:
Town:
Province:
Country:
Postal Code:
Telephone:
Email:
6. Is the applicant known by any other name?
No
Yes, list all names:
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 5
CORPORATE STRUCTURE
7. Has the applicant ever made application for or held any cannabis retail licenses/ approvals in any other jurisdiction?
No
Yes
Check () one
Name & Address of
Regulatory Agency
Contact Name &
Telephone Number
License /
Registration Type
Date Licensed &
Status
Details
8. List of current owners, investors, promoters, parent or holding companies, shareholders and partners (in a partnership).
Individual/Person Name
Position or Relationship
% of
Ownership
CORPORATE STRUCTURE - CONTINUED
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 6
9. List all other corporate entities currently associated to the applicant include all subsidiary companies and those the applicant has a
financial, organizational or managerial interest in. Disclosure may be requested. Provide details as to the nature and extent of any financial,
organizational or managerial interest.
Name
Relationship
Contact Name & Telephone Number
10. List all current directors and officers. (Personal disclosures and must be provided)
Name
Position
11. Total current members of employees - applicant: _______________________________
12. Attach a current organizational chart showing the reporting structure and all key employees.
CORPORATE STRUCTURE - CONTINUED
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 7
13. Has the Applicant ever been licensed/ registered with AGLC? No Yes Check () one
License/ Registration Type
Date Licensed/ Registered & Status
Details
14. Has the Applicant ever been involved in any capacity in the production, distribution or selling of Cannabis? No Yes Check () one
Name & Address of
Regulatory Agency
Date
Contact Name &
Telephone Number
Details
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 8
CRIMINAL / LITIGATION / DISCIPLINARY INFORMATION
Important Information:
Failure to provide full disclosure will be taken into account in assessing the
applicant's character, honesty and integrity and may result in the applicant being
denied a license / registration.
A. An applicant may not be eligible for license/registration if the character, financial history or competence of
the applicant or any associated person (including but not limited to an owner, shareholder, director,
officer, key employee, or partner of any individual shareholder, director, officer or key employee) poses a
threat to the integrity of the retail of cannabis.
B. Enquiries will be made to determine if the applicant or any associated person has ever been charged
with or convicted of, or is subject to pending charges for a criminal, regulatory, civil or other statutory
offence.
C. The applicant and all associated persons must provide full disclosure of all criminal and civil proceedings
on the appropriate disclosures.
D. Failure to disclose any such involvement will be taken into account when assessing the applicant's
eligibility for license/ registration.
E. The particulars of any offence or claim and the sentence or penalty imposed will be reviewed to
determine whether a conviction or charge affects the applicant's eligibility for license/ registration.
F. INSTRUCTIONS
1. Answer "YES" and provide all information even if:
i.
The charges were dismissed or subsequently downgraded to a lesser charge.
ii.
The applicant was not convicted.
If answering yes, ensure you check () the appropriate box and list all incidents as requested.
2. Answer "NO" if any records relating to a charge or conviction have been expunged or otherwise
officially sealed by a court or government agency.
DEFINITIONS:
Charge - includes any indictment, information, summons or other notice of the alleged commission of a
criminal offence.
Arrest - includes any detaining, holding or taking into custody by any law enforcement authority to
answer for the alleged performance of any offence.
Offence - Includes all offences, regardless of the seriousness, under any Federal, Provincial or
Municipal statute, or violations of probation or any other court order.
CRIMINAL / LITIGATION / DISCIPLINARY INFORMATION - CONTINUED
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 9
1. Has the applicant ever been investigated for, charged with or convicted of a criminal offence or other violation of any statute, regulation or
code?
No Yes Check () one
Date
Reason for Investigation, Charge or
Conviction
Disposition and Sentence
Enforcement Agenda Name and
Location
2. Has the applicant ever had any cannabis retailer license/approval denied, suspended, revoked or made subject to any sanctions or fines?
No Yes Check () one
Type of
License/Registration
Name of Licensing Agency and Contact Name and
Telephone Number
Date and Reason(s) for Denial, Suspension,
Revocation or Condition
3. Has the applicant ever been defendant or plaintiff in a lawsuit in the last five years? (Include all collection matters, debt matters,
bankruptcy, insolvency or liquidation).
No Yes Check () one
Date of Order,
Judgement or Decree
Docket/File Number
Details
Issuing Court and Location
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 10
COMPANY REPRESENTATIVE
STATUTORY DECLARATION
COMPANY REPRESENTATIVE COMPLETING APPLICATION
Name:
Position:
Address:
Telephone:
Town:
Province:
Fax:
Country:
Postal Code:
Email:
I, _____________________________________________
(PRINT Company Representative Name)
DO SOLEMNLY DECLARE THAT
1. I have prepared this disclosure on behalf of _______________________________________, the applicant.
2. I have provided an answer to every question on this disclosure.
3. The information provided is true, accurate and complete to the best of my knowledge, and all required
disclosures and other documentation have been provided.
4. Any document accompanying this disclosure that is not an original document is a true copy of the original
document.
I MAKE this solemn declaration conscientiously believing it to be true and knowing that is of the same force and
effect as if made under oath.
Declared before me at ______________________________ in the province of ____________________________
This ________________ day of ________________________, A.D., 20 ______.
___________________________________________________
Company Representative Signature
___________________________________________________
_________________________________
Notary Public, Justice of the Peace, Commissioner of Oaths,
My Appointment Expires
or other Individual Authorized to take Declarations.
Applicant Disclosure - Cannabis
Initial: ______ Date: _______
RESTRICTED WHEN COMPLETED
Page 11
APPLICANT OWNER/PRESIDENT
STATUTORY DECLARATION
Applicant Full Legal Name: ____________________________________________________________________
I, ______________________________________________ (Applicant Owner or President)
Of the Town of ___________________________________ in the Province of _____________________________
DO SOLEMNLY DECLARE THAT
1. I have read this Applicant Disclosure for License/Registration Application and have verified all information
contained in it.
2. I have personally initialed and dated each page of this Applicant Disclosure declaring that the information
provided is true, accurate and complete to the best of my knowledge.
I MAKE this solemn declaration conscientiously believing it to be true and knowing that it is the same force and
effect as if made under oath.
Declared before me at ______________________________ in the province of ____________________________
This ________________ day of ________________________, A.D., 20 ______.
___________________________________________________
Applicant Owner or President's Signature
___________________________________________________
_________________________________
Notary Public, Justice of the Peace, Commissioner of Oaths,
My Appointment Expires
or other Individual Authorized to take Declarations.