Marijuana Program Patient Attestation Form - Arizona Department Of Health Services
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1MARIJUANA PROGRAM PATIENT ATTESTATION
I, __________________________________ , attest that:
I will not divert marijuana to any individual who or entity that is not
allowed to possess marijuana pursuant A.R.S. Title 36, Chapter 28.1 and
that the information provided in the application is true and correct.
______________________________________
___________________________________
Signature
Date Signed
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