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Application A: Applicant With a Permanent Canadian Address Application B: Applicant Without a Permanent Canadian Address Application C: Health Care Practitioner to Receive Applicant’s Product

Applicant Information

First Name

Last Name

Date of Birth

A valid date of birth is required.

Applicant must be at least 18 years old.

Gender

Male

Female

Other

This field is required.

Applicant is a Veteran

Veteran Medavie Blue Cross Number

CARP Member Number

Phone Number

A valid phone number is required.

Ext.

A valid email address is required.

Fax Number

Fax number is invalid.

Password

Please choose a password at least 8 characters long.

Repeat Password

Passwords must match.

Residential & Shipping Information

Care Home Information

Establishment Name

Establishment Type

Manager First Name

Manager Last Name

Contact Information

Phone Number

A valid phone number is required.

Ext.

A valid email address is required.

Fax Number

Fax number is invalid.

Residential Address

Establishment Address

Address Line 1

Address Line 2

City

Province

Postal Code

A valid postal code is required.

Mailing Address

Mailing address is the same as Residential address Mailing address is the same as Establishment address

Address Line 1

Address Line 2

City

Province

Postal Code

A valid postal code is required.

Shipping Address

Please Ship To:

Residential Address Establishment Address

Mailing Address

This field is required.

Applicant may be contacted by:

Phone

Letter mail to residence Letter mail to establishment

Letter mail to mailing address

Statement of Responsibility By Manager

I, , attest that I am a manager of the establishment listed above, which provides food, lodging or other social services to the Applicant, .

Manager’s Signature

× Clear

A signature is required.

Date: 2019-10-20

Responsible Person Information

Responsible Person Applying On Behalf Of Applicant

I am the applicant

I am a responsible person applying on behalf of the applicant

This field is required.

First Name

Last Name

Date of Birth

A valid date of birth is required.

Responsible person must be at least 18 years old.

Gender

Male

Female

Other

This field is required.

Phone Number

A valid phone number is required.

Ext.

A valid email address is required.

Fax Number

Fax number is invalid.

Statement of Responsibility

I, , confirm I am legally responsible for .

Responsible Person’s Signature

× Clear

A signature is required.

Date: 2019-10-20

Health Care Practitioner Information

Profession

Physician

Nurse

Other

This field is required.

License Number

Issuing Province

First Name

Last Name

Phone Number

A valid phone number is required.

Ext.

A valid email address is required.

Fax Number

Fax number is invalid.

Clinic/Business Name

Clinic/Business Address

Address Line 1

Address Line 2

City

Province

Postal Code

A valid postal code is required.

Clinic Mailing Address

Mailing address is the same as residential address

Address Line 1

Address Line 2

City

Province

Postal Code

A valid postal code is required.

Clinic Shipping Address

Please Ship To:

Clinic/Business Address

Clinic Mailing Address

This field is required.

Statement of Responsibility By Manager

I, , consent to receive dried cannabis or cannabis oil on behalf of .

Health Care Practitioner’s Signature

× Clear

A signature is required.

Date: 2019-10-20

Documents & Attestation

For documentation, I am supplying:

Original of the applicant’s medical document

Copy of registration certificate issued by the Minister

This field is required.

Document Attestation

By checking this box, I verify the following:

The applicant ordinarily resides in Canada;
The information in the application and the medical document is correct and complete;
The medical document is not being used to seek or obtain dried marihuana from another source;
The original of the medical document accompanies the application; and
The applicant will use dried marihuana only for their own medical purposes.

The applicant ordinarily resides in Canada;
The information in the application and the registration certificate is correct and complete;
If the application is being made for the purpose of obtaining cannabis, the registration certificate is not being used to seek or obtain those substances from another source;
The applicant will use those substances only for their own medical purposes.

Digital Signature

Applicant or Responsible Person’s Signature

× Clear

A signature is required.

Date: 2019-10-20

Your registration was submitted successfully!

Soon you should receive a customer account activation email.

[More copy explaining that it'll still be a little while before your submission has been verified by staff and you can actually purchase anything… or will it? Thoughts?]

Having issues? Contact us.