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SELECT ITEM TYPE:

Raw marijuana (THC) CBD Product (Non-THC product) Concentrate / Extract / Oil (THC &/or CBD) Edible product Raw cannabis plant material – (Unknown THC / CBD) Topical cream, lotions, transdermal patch (THC &/or CBD)

Batch Number (use commas to separate different batch ID's)

Claimed Potency % THC/CBD

Package Weight (in grams)

Volume of Product (Liquid)

Cost of individual item (before tax)

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SELECT ANOTHER ITEM TYPE (if applicable):

Batch Number (use commas to separate different batch ID's)

Claimed Potency % THC/CBD

Package Weight (in grams)

Volume of Product (Liquid)

Cost of individual item (before tax)

____________________________________________________________________________________________________________________________________________________________________

SELECT ANOTHER ITEM TYPE (if applicable):

Batch Number (use commas to separate different batch ID's)

Claimed Potency % THC/CBD

Package Weight (in grams)

Volume of Product (Liquid)

Cost of individual item (before tax)

____________________________________________________________________________________________________________________________________________________________________

SELECT ANOTHER ITEM TYPE (if applicable):

Batch Number (use commas to separate different batch ID's)

Claimed Potency % THC/CBD

Package Weight (in grams)

Volume of Product (Liquid)

Cost of individual item (before tax)

____________________________________________________________________________________________________________________________________________________________________

SELECT ANOTHER ITEM TYPE (if applicable):

Batch Number (use commas to separate different batch ID's)

Claimed Potency % THC/CBD

Package Weight (in grams)

Volume of Product (Liquid)

Cost of individual item (before tax)

Dispensary/Business Name

Dispensary/Business Address

Total tax paid on all purchases (as listed on receipt)

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