Michigan Medical Marihuana Program - State Of Michigan Page 2

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For Official Use Only

MMP 3501 (Rev. 1/15)

$60 Patient (with no caregiver) Fee Received

□

□ $85 Patient (with caregiver) Fee Received

Michigan Medical Marihuana Program

Application Form for Registry Identification Card

(517) 284-6400 |

Section A: Patient Information (REQUIRED) as it appears on your identification

1. Legal First Name

2. Middle Initial

3a. Legal Last Name

3b. Suffix (Jr., Sr., III, etc.)

4. Patient Registry ID Card Number (For Renewals Only)

5. MI Driver’s License# or MI ID Card #

6. Date of Birth

(MM/DD/YYYY)

7a. Mailing Address

7b. Apartment/Suite/Lot #

8. City

9. State

10. Zip Code

11. Email Address (If provided, you agree to receive email correspondence from MMMP)

12. Telephone Number

Section B: Person Allowed to Possess Patient’s Marihuana Plants: (REQUIRED)

Plant possession: You must select one box. Failure to do so will result in the denial of your application.

13.

SELECT ONLY ONE:

I will possess the plants

My caregiver will possess the plants

Section C: Caregiver Information (If the patient is designating a caregiver)

14. Legal First Name

15. Middle Initial 16a. Legal Last Name

16b. Suffix (Jr., Sr., III, etc.)

17. Caregiver Registry Card ID Number (For Renewals Only)

18. MI Driver’s License# or MI ID Card #

19. Date of Birth

(MM/DD/YYYY)

20a. Mailing Address

20b. Apartment/Suite/Lot #

21. City

22. State

23. Zip Code

24. Email Address (If provided, you agree to receive email correspondence from MMMP)

25. Telephone Number

26. Other Names Used by Caregiver (Nicknames, maiden names etc. Use a separate piece of paper if you need space for additional names)

Section D: Caregiver Patient Signature & Date (Required)

I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated Law 1 of

2008, MCL 333.26421 et seq.), Administrative Rules and amendments thereafter. I understand that a false or fraudulent statement, with the intent to aid, abet, or

assist in defrauding the state is guilty of perjury punishable in the manner provided by law.

Signature of Patient/Applicant:

Date:

______________________

Signature of Caregiver:

Date:

_______________________

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