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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

A valid date of birth is required.
Applicant must be at least 18 years old.
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A valid phone number is required.
A valid email address is required.
Fax number is invalid.
Please choose a password at least 8 characters long.
Passwords must match.

Residential & Shipping Information

Care Home Information

Contact Information

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A valid email address is required.
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Residential Address

Establishment Address

A valid postal code is required.

Mailing Address

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Shipping Address

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Statement of Responsibility By Manager

× Clear
A signature is required.

2019-12-12

Responsible Person Information

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A valid date of birth is required.
Responsible person must be at least 18 years old.
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A valid phone number is required.
A valid email address is required.
Fax number is invalid.

Statement of Responsibility

× Clear
A signature is required.

2019-12-12

Health Care Practitioner Information

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A valid phone number is required.
A valid email address is required.
Fax number is invalid.

Clinic/Business Address

A valid postal code is required.

Clinic Mailing Address

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Clinic Shipping Address

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Statement of Responsibility By Manager

× Clear
A signature is required.

2019-12-12

Documents & Attestation

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Document Attestation

  • 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

× Clear
A signature is required.

2019-12-12

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?]

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