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 4
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4Department of Licensing and Regulatory Affairs
DLARA/MMP-030 (Rev. 4/11)
Michigan Medical Marihuana Registry
P.O. Box 30083
Lansing, MI 48909
Caregiver Attestation
INSTRUCTIONS: Please complete all required information in order to comply with the requirements of the Michigan
Medical Marihuana Registry.
PLEASE TYPE OR PRINT LEGIBLY
DECLARATION: (REQUIRED)
I,
, do hereby declare:
______________________________________________________________________________
CAREGIVER’S NAME (PRINTED)
that I am willing and able to serve as the primary caregiver for:
____________________________________________________________________________
PATIENT’S NAME (PRINTED)
I further certify that:
I am at least 21 years of age
I have never been convicted of a felony offense involving illegal drugs
I understand that my caregiver registration will become null and void if I am convicted of a felony
offense involving illegal drugs
I am a caregiver for no more than 5 patients
I have submitted a copy of my photo ID to my qualifying patient to submit with this application
PRIMARY CAREGIVER INFORMATION: (REQUIRED)
MAILING ADDRESS
TELEPHONE NUMBER
(
)
CITY
STATE
ZIP CODE
ALTERNATE PHONE NUMBER
MI
(
)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
-
-
/
/
OTHER NAMES USED-including maiden names for females: (REQUIRED, IF APPLICABLE)
Attach a separate page if more space required
(First, M.I., Last)
(First, M.I., Last)
(First, M.I., Last)
I understand that it is necessary to secure a criminal conviction history as part of the screening process.
I authorize this agency to use the information provided in this application to obtain a criminal conviction
history file search from the Central Records Division of the Michigan Department of State Police or other law
enforcement or judicial recordkeeping organization to verify if I have been convicted of any felony offenses
involving illegal drugs.
The statements in this application are true and correct.
I have not withheld
information that might affect the decision to be made on this application. In signing this application, I am
aware that a false statement or dishonest answer may be grounds for denial of my application or revocation
of my registration and that such misrepresentation is punishable by law.
__________________________________________________________________________
_____________________
Signature of Primary Caregiver
Date
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