Oregon Medical Marijuana Program Application Form Page 2
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1
2Oregon Medical Marijuana Program
OFFICIAL USE ONLY
CHC
FS
OHP
SSI
APPLICATION FORM
Complete all sections marked REQUIRED.
Please type or print legibly. Do not alter this form or use white out.
REQUIRED
PATIENT INFORMATION
Male
Female
LEGAL NAME (LAST, FIRST, M.I.):
DATE OF BIRTH:
MAILING ADDRESS:
PHONE #:
CITY:
STATE:
ZIP CODE:
COUNTY:
Photo Identification: A photocopy of one of the current following ID types must be attached. Please check appropriate box:
[ ] OR DL / ID #: _____________________
[ ] Other US State or Federal Issued ID#: ____________________
OPTIONAL
CAREGIVER INFORMATION (Not your physician)
Male
Female
LEGAL NAME (LAST, FIRST, M.I.):
DATE OF BIRTH:
MAILING ADDRESS:
PHONE #:
CITY:
STATE:
ZIP CODE:
COUNTY:
Photo Identification: A photocopy of one of the current following ID types must be attached. Please check appropriate box:
[ ] OR DL / ID #: _____________________
[ ] Other US State or Federal Issued ID #: ____________________
REQUIRED
GROWER INFORMATION
Male
Female
LEGAL NAME (LAST, FIRST, M.I.):
DATE OF BIRTH:
MAILING ADDRESS:
PHONE #:
CITY:
STATE:
ZIP CODE:
COUNTY:
Photo Identification: A photocopy of one of the current following ID types must be attached. Please check appropriate box:
[ ] OR DL / ID #: _____________________
[ ] Other US State or Federal Issued ID #: ____________________
REQUIRED
GROWSITE INFORMATION
PHYSICAL ADDRESS:
CITY:
OREGON
ZIP CODE:
COUNTY:
REQUIRED
APPLICATION and GROWSITE REGISTRATION FEE
PATIENT IS HIS/HER OWN GROWER AND:
PATIENT IS NOT HIS/HER OWN GROWER AND:
Submits no reduced fee proof: $200.00
Submits no reduced fee proof: $250.00
Submits current SNAP proof:
$60.00
Submits current SNAP proof:
$110.00
Submits current OHP proof:
$50.00
Submits current OHP proof:
$100.00
Submits current SSI proof:
$20.00
Submits current SSI proof:
$70.00
**OMMP FEES ARE NON-REFUNDABLE**
Enclose your check or money order payable to “OMMP” or
. Please indicate on your check or money
“OHA/State of Oregon”
order who the payment is for. We do not accept debit/credit cards. This form must accompany payment. Do not staple or
paperclip attachments. See opposite side for additional fee information.
REQUIRED
SIGNATURE & DATE
I TESTIFY THAT THE ABOVE INFORMATION IS TRUE:
APPLICANT SIGNATURE:
DATE:
Do Not Fax
Rev 10/13
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