Application For A Designated Caregiver Registry Identification Card

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CG
State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for a Designated Caregiver Registry Identification Card
***Do not use this form for Terminal Illness***
APPLICATION TYPE (Check the appropriate answer)
New: I have never had an Illinois Medical Cannabis Designated Caregiver Registry Identification Card.
New with Current Patient: I have never had an Illinois Medical Cannabis Designated Caregiver Registry
Identification Card, but I am applying to be a caregiver for a patient who has already been approved.
CAREGIVER 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
QUALIFYING PATIENT INFORMATION
First Name
Middle Name
Last Name
Home Address
Apartment or Suite #
City
State
ZIP Code
IL
Telephone Number (###-###-####)
E-mail Address
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
_____________________________________________________________
____________________________
SIGNATURE of Qualifying Patient
DATE (mm/dd/yyyy)
This application was prepared by:
_____________________________________________________________
____________________________
PRINT/TYPE PREPARER’S NAME
DATE (mm/dd/yyyy)
_____________________________________________________________
____________________________
FIRM OR ORGANIZATION NAME
PHONE NUMBER
Page 1 of 4
Printed by Authority of the State of Illinois
IOCI 17-8
P.O.#3117020
5M
9/16

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