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Medical Use Of Marijuana Program - State Of Maine Department Of Health And Human Services Page 2

SECTION 4: Caregiver Designation (Complete only if designating a Caregiver)

Legal Name:

Telephone No.: (

)

Street Address:

City:

State:

Zip:

County:

Caregiver MMMP Registration # assigned to this patient:

(if cultivating for the patient and registration is required)

Primary caregiver registration required; EXCEPTIONS, Section 5.4

o Section 5.4.1: A primary caregiver designated to cultivate for a qualifying patient if that qualifying patient Is a

member of the household of that primary caregiver;

o Section 5.4.2: Two primary caregivers who are also both qualifying patients, if those primary caregivers are

members of the same household and assist one another with cultivation;

o Section 5.4.3: A primary caregiver who cultivates for a qualifying patient if that qualifying patient is a member of

the family of that primary caregiver (see 22MRSA 2423-A (3) (C)

SECTION 5: Dispensary Designation (Complete only if designating a Dispensary)

Name of Dispensary:

City:

Telephone No.: (

)

Name of Dispensary Representative:

Name of Non Grow Caregiver, if any, who may pick up marijuana for me at the dispensary:

SECTION 6: Expiration and Renewal of Designation

Expiration:

This designation form expires on (month/day/year) _______________, or no later than 12 months after the signature

date in Section 7, whichever comes first.

Renewal:

The patient is required to complete a new designation form in order to renew the designation of a caregiver or

dispensary.

Page 2 of 3

Form 110103 Rev 12/2012

Medical Use Of Marijuana Program - State Of Maine Department Of Health And Human Services Page 2