Medical Use Of Marijuana Program - State Of Maine Department Of Health And Human Services
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1
2
3STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF LICENSING AND REGULATORY SERVICES
-
Medical Use of Marijuana Program
Designation Form
(For patients to designate a caregiver or dispensary)
SECTION 1: Patient Information
Legal Name:
Date of Birth:
Driver’s License No.:
Telephone No.: (
)
Home Address:
City:
State:
Zip:
County:
Expiration date of Physician Certification:
SECTION 2: Cultivation Authorization
May only allocate up to 6 plants
_____ # of plants I will grow
_____# of plants my caregiver will grow
_____# of plants my dispensary will grow
May Designate caregiver or dispensary-Not both
Total # (Not to exceed 6) _________
SECTION 3: Marijuana Transportation
How will the medical marijuana be transported? (Check all that apply)
□
I will pick up the marijuana from my designated caregiver/dispensary.
□
The designated caregiver/dispensary will deliver my marijuana to me.
□
Name of designated caregiver. (See Caregiver information section 4)
For questions regarding this program and/or application, please contact the following:
Department of Health and Human Services
Licensing and Regulatory Services
Maine Medical Use of Marijuana Program
41 Anthony Ave
11 State House Station
Augusta, ME 04333-0011
Tel: (207) 287-4325
Fax: (207) 287-2671
Toll Free: 1-800-791-4080
TTY users call Maine relay 711
Email:
medmarijuana.dhhs@maine.gov
Office Use Only:
Check# ___________
MO # ________________________ Amount $___________ Initials: ________ License# ______________
Page 1 of 3
Form 110103 Rev 12/2012
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