Medical Marihuana Review Panel Petition (Page 2 of 5) in pdf

Medical Marihuana Review Panel Petition Page 2

MEDICAL MARIHUANA REVIEW PANEL PETITION

Please complete each section of this petition. If there are any supportive documents attached

to this petition, you must reference these documents in the text of your petition. Any petitions

that are not fully or properly completed will be returned within 30 days for proper completion and

resubmission. If you need additional space for any item, please use an attached sheet of paper

and properly number the item.

1. Petition Applicant Information

Name:___________________________________________________________________

Address:_________________________________________________________________

Phone Number: (H)_________________ (W)_______________ (C)__________________

Email: __________________________ Additional Email: __________________________

2. Medical Condition Proposed. Please be specific. Do not submit broad categories

(such as “mental illness”) or ones that contradict the Medical Marihuana Act (such as

“conditions resulting in hospitalization” or “all hospice patients”).

________________________________________________________________________

3. Provide justification for why this medical condition should be included as a

qualifying debilitating medical condition for the use of medical marihuana.

Specifically, why doesn’t this condition adequately fall under one of the already

approved qualifying medical conditions for the use of medical marihuana in Michigan?

Medical Marihuana Review Panel Petition Page 2