Application For A Designated Caregiver Registry Identification Card (Page 4 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

REQUIRED DOCUMENTS

Place the following items in an envelope and attach to fingerprint consent form:

❑

Non-refundable application fee (Check or Money Order to Illinois Department of Public Health)

❑

Photograph

• Taken in the last 30 days

• Taken against a plain, white or off-white background or backdrop

• In natural color (Do not use a filter)

• Full-face view directly facing the camera with a neutral facial expression and both eyes open

• At least 2 inches by 2 inches in size

It is recommended you use a passport photo vendor to ensure the photograph meets these requirements.

Contact the Division of Medical Cannabis if a photograph is in violation of or contradictory to the qualifying patient’s religious

convictions.

Attach the following supporting documents to the fingerprint consent form:

❑

Proof of age and identity

Submit a clear, color copy of an Illinois Driver’s License, Illinois State ID, or the photograph page of a US passport.

❑

Proof of residency

If your Driver’s License, Temporary Visitor Driver's License or State ID address matches your application submit one additional

proof of residency. If you submit a US Passport as your proof of identity or your Driver’s License or State ID address does not

match the address on your application, submit two of the following:

• Pay stub or electronic deposit receipt, issued less than 60 days prior to the application date, that shows evidence of

withholding for State income tax

• Valid voter registration card with an address in Illinois

• Current military identification card;

• Bank statement (dated less than 90 days prior to application) or credit card statement (dated less than 60 days prior to

application);

• Deed/title, mortgage or rental/lease agreement; property tax bill;

• Insurance policy (current coverage for automobile, homeowner's, health or medical, or renter's);

• Medical claim or statement of benefits (from a hospital or health clinic, private insurance company or public (government)

agency, dated less than 12 months prior to application)

• Tuition invoice/official mail from college or university, dated less than the 12 months prior to application

• Utility bill, including, but not limited to, those for electric, water, refuse, telephone land-line, cellular phone, cable or gas,

issued less than 60 days prior to application

• W-2 from the most recent tax year

Proof of residency must include name and address and match the address on the application

❑

Fingerprint receipt

A listing of live scan fingerprint vendors can be found at https:// Contact the

live scan fingerprint vendor before having fingerprints taken to make sure they take Medical Cannabis fingerprints. Remember

to bring the fingerprint consent form to the vendor and add the Transaction Control Number (TCN) to your form. Once you have

your fingerprints taken, the fingerprint consent form and the receipt provided by the live scan fingerprint vendor containing the

TCN must be sent in with your application. Fingerprints must be taken within 30 days of submitting your application.

Mail the application and required documents to:

Illinois Department of Public Health

Division of Medical Cannabis

535 West Jefferson Street

Springfield, Illinois 62761-0001

Questions? Contact the Division of Medical Cannabis at 855-636-3688 or DPH.MedicalCannabis@Illinois.gov.

Page 4 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 4

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