Application For A Designated Caregiver Registry Identification Card (Page 2 of 4) in pdf

State of Illinois

Illinois Department of Public Health

Illinois Medical Cannabis Pilot Program

Application for a Designated Caregiver Registry Identification Card

ATTESTATIONS

I certify the information provided in this application is true and accurate to the best of my knowledge.

Submission of false, misleading, or inaccurate information in connection with this application is grounds for revocation of my

Illinois Medical Cannabis Designated Caregiver Registry Identification Card and other administrative, civil or criminal penalties.

I additionally certify that I have been given actual Notice and understand that, notwithstanding the Compassionate Use of Medical

Cannabis Pilot Program Act (Act):

(i) cannabis is a prohibited Schedule I controlled substance under federal law;

(ii) participation in the program is permitted only to the extent provided by the strict requirements of the Act;

(iii) any activity not sanctioned by the Act may be a violation of state or federal law and could result in arrest, conviction, or incar-

ceration;

(iv) growing, distributing, or possessing cannabis under the Act, unless done through a federally-approved research program, is a

violation of federal law;

(v) growing, distributing, or possessing cannabis in any capacity, except through a federally-approved research program, may

be a violation of state or federal law and could result in arrest, conviction or incarceration;

(vi) use of medical cannabis, or possessing a medical cannabis patient or caregiver registry card, may affect an individual’s

ability to receive or retain federal or state licensure in other areas;

(vii) use of medical cannabis or possessing a medical cannabis patient or caregiver registry card, in tandem with other conduct,

may be a violation of state or federal law and could result in arrest, conviction or incarceration;

(viii) participation in the Medical Cannabis Pilot Program does not authorize any person to violate federal law or state law,

(ix) the Act does not provide any immunity from or affirmative defense to arrest or prosecution under federal law or state law, other

than as set out in 410 ILCS 130/25; and

(x) applicants shall indemnify, hold harmless, and defend the state of Illinois for any and all civil or criminal penalties resulting

from participation in the program.

_____________________________________________________________

____________________________

SIGNATURE

DATE (mm/dd/yyyy)

APPLICATION FEES

Provide a check or money order payable to Illinois Department of Public Health.

Choose One:

Application Fee for Designated Caregiver

❑

$25 – One-Year Registry Card

❑

$50 – Two-Year Registry Card

❑

$75 – Three-Year Registry Card

❑

$75 – Caregiver applying separately for a patient who has already been registered

(the expiration date for the caregiver and the patient card will be the same)

APPLICATION FEES ARE NOT REFUNDABLE

Page 2 of 4

Printed by Authority of the State of Illinois

IOCI 17-8

P.O.#3117020

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Application For A Designated Caregiver Registry Identification Card Page 2

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