State Of Maine Department Of Health And Human Services Division Of Licensing And Regulatory Services Medical Use Of Marijuana Program Caregiver Application

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STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF LICENSING AND REGULATORY SERVICES
Medical Use of Marijuana Program
Caregiver Application
SECTION 1: Caregiver Information
New Applicant
Renewal
Adding Patient (Max of 5)
Legal Name:
Date of Birth:
Telephone No.: (
)
(Must be at least 21)
Home Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Email Address:
SECTION 2: Fees
License Type (Select One):
Nursing Facility - No Fee
Hospice - No Fee
$ ___________
Primary Caregiver (NOT growing marijuana) - Mandatory $31 fee for background checks
Primary Caregiver (Growing marijuana) – Please complete below:
$ ___________
Number of patients (maximum of 5): __________ multiplied by $240 cultivation fee =
$ ___________
Caregiver Criminal Background Check: $31.00 (Mandatory Annually)
The exceptions for the $240 cultivation fee are found in the Rules Governing the Maine Medical Use of
Marijuana Program Section 5.4
____________________
If one of the exceptions apply, please identify the patient/caregiver relationship
All Fees are non-refundable
(Section 7.1 MMMP rules)
Make bank check or money order payable to “Treasurer, State of Maine”.
We are unable to accept personal checks, cash and credit cards.
Total Bank Check/Money Order enclosed:
$ ___________
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
DHHS.MMMP@maine.gov
Email:
Website:
Office Use Only:
Check# ___________
MO # ________________________ Amount $___________ Initials: ________ License# ______________
Page 1 of 3
Form 110101 Rev 1/2015

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