Illinois Medical Cannabis Program Application For Registry Identification Card For Qualifying Patients Under 18 Years Of Age And Their Designated Caregivers Page 4
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7State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for Registry Identification Card for
Qualifying Patients Under 18 Years of Age and their Designated Caregivers
NEW APPLICATION OR RENEWAL (Check the appropriate answer)
New: I have never had an Illinois Medical Cannabis Registry Identification Card.
Renewal: I have had an Illinois Medical Cannabis Registry Identification Card.
My Registry Identification Card Number is ________________________.
QUALIFYING PATIENT INFORMATION
Social Security Number (### - ## - ####)
Drivers License # (if applicable):
Driver’s License State (if applicable):
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
PHYSICIAN INFORMATION
Name of Hospital, University or Practice
First Name
Middle Name
Last Name
Office Address
Suite #
City
State
ZIP Code
IL
Office Telephone Number (###-###-####)
E-mail Address
Page 1 of 4
Printed by Authority of the State of Illinois
IOCI 15-164
P.O.#3115001
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Parent category: Medical