Form Dlara/mmp-500 - Instructions For Applying For A Medical Marihuana Registry Identification Card/form Dlara/mmp-010 - Application Form For Registry Identification Card/etc. Page 2
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4DLARA/MMP-010 (Rev. 4/11)
Department of Licensing and Regulatory Affairs
FOR OFFICIAL USE ONLY
Michigan Medical Marihuana Registry
P.O. Box 30083
Lansing, MI 48909
APPLICATION FORM FOR
REGISTRY IDENTIFICATION CARD
INSTRUCTIONS:
Please complete all required information to comply with the registration requirements of the
Michigan Medical Marihuana Registry.
Attach readable copies of photo ID(s) and your registration fee.
The registration fee for this application is $100.00 or $25.00 if the patient is enrolled in Medicaid or receiving
SSI or SSD (copies of qualifying documentation must be attached). Enclose your check or money order
made payable to State of Michigan—MMMP. We do not accept Cash, Credit Cards, or Debit Cards.
PLEASE TYPE OR PRINT LEGIBLY
APPLICANT/PATIENT INFORMATION: (REQUIRED)
Section A:
NAME (First, M.I., Last)
Male
Female
SOCIAL SECURITY NUMBER
DATE OF BIRTH
-
-
/
/
MAILING ADDRESS
PHONE NUMBER
(
)
CITY
STATE
ZIP CODE
ALTERNATE PHONE NUMBER
MI
(
)
Photo Identification: A clear photocopy of one of the following must be attached. Please check appropriate box:
MI Driver’s License or MI ID Card #______________________________________
Other__________________________
PRIMARY CAREGIVER: (IF APPLICABLE)
Section B:
NAME (First, M.I., Last)
Male
Female
SOCIAL SECURITY NUMBER
DATE OF BIRTH
-
-
/
/
MAILING ADDRESS
TELEPHONE NUMBER
(
)
CITY
STATE
ZIP CODE
ALTERNATE PHONE NUMBER
MI
Photo Identification: A clear photocopy of one of the following must be attached. Please check appropriate box:
MI Driver’s License or MI ID Card #______________________________________
Other__________________________
PERSON ALLOWED TO POSSESS PATIENT’S MARIHUANA PLANTS: (REQUIRED)
Section C:
ONE: APPLICANT/PATIENT
PRIMARY CAREGIVER
SELECT
OR
(Caregiver Attestation & photo ID Required)
If neither or both boxes are checked above, plant possession will default to the Applicant/Patient.
CERTIFYING PHYSICIAN INFORMATION: (REQUIRED)
Section D:
PHYSICIAN’S NAME
MAILING ADDRESS
TELEPHONE NUMBER
(
)
ATTESTATION, SIGNATURE, & DATE: (REQUIRED)
Section E:
By signing below, I attest that the information I have entered on this application is true and accurate:
__________________________________________________________________________
_____________________
Signature of Applicant/Patient
Date
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Parent category: Medical