State Of Maine Department Of Health And Human Services Division Of Licensing And Regulatory Services Medical Use Of Marijuana Program Caregiver Application Page 3

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SECTION 7: Declaration
•
I UNDERSTAND and acknowledge my duties as a caregiver.
•
I UNDERSTAND that my authorization to grow medical marijuana is contingent on my possessing a valid
caregiver designation form for each patient for whom I grow medical marijuana.
•
I AGREE to return the caregiver designation form and designation card to the patient if the patient informs me
that he or she no longer wants me to be his or her caregiver.
•
I ACKNOWLEDGE that I have only 10 days from that notice to either destroy excess marijuana or to replace the
patient with a new patient.
•
I AGREE that in the event that law enforcement questions my status as a caregiver, that I will make available for
verification to law enforcement, copies of each caregiver designation form upon which I rely on to support the
amount of medical marijuana in my possession.
•
I UNDERSTAND that if I do not comply with these requirements, the Department of Health and Human Services
may revoke authorization to serve as a caregiver under the Maine law.
•
I DECLARE under penalty of perjury that the information provided on this form is true and correct.
•
I UNDERSTAND that I must submit a new caregiver application each time I apply for a card and/or renew a card.
•
I CERTIFY that I will not sell, furnish, or give marijuana to a person who is not allowed to possess marijuana for
medical purposes.
•
I UNDERSTAND that I may employ only one person to assist in performing the duties of the primary caregiver.
•
I UNDERSTAND that my employee must register with the State of Maine in accordance with state law.
•
I FURTHER AGREE that I will report sales tax related to the sale of marijuana by me to a qualifying patient.
•
I UNDERSTAND that all fees are nonrefundable (SECTION 7.1 MMMP RULES)
_______________________________________ _____________________________________ ____________________
Print name of Caregiver
Signature of Caregiver
Date
Page 3 of 3
Form 110101 Rev 1/2015

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