Form A

1. Applicant Information

Applicant's Name

Surname * Given Name *

Date of Birth *

Gender * Male Female Unspecified

Address Line 1:

Street * Postal Code *

Address Line 2:

City * Province * Fax Number

Email Address * Phone *

Mailing Address Line 1: (if different from residence)

Street Postal Code

Mailing Address Line 2:

City Province Fax Number

Phone

Shipping Address Line 1: (if different from mailing address)

Street Postal Code

Shipping Address Line 2:

City Province Fax Number

Phone

2. Individual (s) Responsible for the Applicant

(If you have caregiver(s), please complete this section)

Person 1 Name :

Surname Given Name

Date of Birth

Gender Male Female Unspecified

Email Address Phone

name of caregiver

am responsible for

applicant name

Individual responsible for Applicant

Signature Date

Person 2 Name :

Surname Given Name

Date of Birth

Gender Male Female Unspecified

Email Address Phone

name of caregiver

am responsible for

applicant name

Individual responsible for Applicant

Signature Date

3. Additional Information

(optional)

Is there anything else You would like us to know?

4. Acknowledgement

The Applicant and/ or the Person Responsible for the Applicant Must Read and Acknowledge the Following:

* The applicant is ordinarily a resident of Canada.

* The individual signing the statement, in the case that an adult who is responsible for the applicant is signing the application, is responsible for the applicant.

* The information in the application and medical document is correct and complete.

* The medical document is not being used to seek or obtain fresh or dried cannabis, or cannabis oil from another source.

* The original medical document accompanies this application.

* The original medical document used to form the basis of this application has not, to the knowledge of the individual signing the statement, been altered.

* The applicant will use fresh or dried cannabis or cannabis oil only for their own medical purposes.

Applicant/ Individual Responsible Signature *

Date *

IMPORTANT NOTE

When returning this application please include the original medical document signed & dated by your health care practitioner. The original copy of the medical document is required to complete your registration.