Application For Qualifying Patient Registry Identification Card
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State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for Qualifying Patient Registry Identification Card
NEW APPLICATION OR RENEWAL (Check the appropriate answer)
New:
I have never had an Illinois Medical Cannabis Registry Identification Card.
❑
Renewal:
I have had an Illinois Medical Cannabis Registry Identification Card.
❑
My Registry Identification Number is QP.________________________.
QUALIFYING PATIENT INFORMATION
Social Security Number (###-##-####)
Driver’s License Number
Driver’s License State
No Driver’s License
❑
First Name
Middle Name
Last Name
Home Address
Apartment or Suite Number
City
County
State
ZIP Code
IL
Telephone Number (###-###-####)
E-mail Address
Date of Birth (mm/dd/yyyy)
Gender
❑
❑
Male
Female
Are you an active duty law enforcement officer, correctional officer,
Do you have a school bus permit or a Commercial Driver’s
correctional probation officer or firefighter?
License?
❑
❑
❑
❑
Yes
No
Yes
No
PHYSICIAN INFORMATION
First Name
Middle Name
Last Name
Office Address
Suite Number
City
State
ZIP Code
IL
MEDICAL CANNABIS DISPENSARY SELECTION
Name and Address of Dispensary
Dispensary District
You must select a dispensary to enter and purchase medical cannabis. The list of dispensaries currently licensed by the state of Illinois
may be viewed at
Page 1 of 4
Printed by Authority of the State of Illinois
IOCI 16-532
P.O.#3116010
10M
3/16
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Parent category: Medical