Form R Application For Renewal Of Authorization To Possess Medical Marihuana The Medical Marijuana Mission (Page 3 of 3) in pdf

Form R Application For Renewal Of Authorization To Possess Medical Marihuana The Medical Marijuana Mission Page 3

R3 Information on Medical Practitioner

Medical practitioner’s full name:

Provincial medical licence number:

STAMP (IF AVAILABLE)

Business Address:

Suite Number:

City:

Province:

Postal Code:

Telephone: (

)

Fax:

(

)

E-mail:

R4-A Medical Practitioner's Declaration and Signature

I declare that I am the treating medical practitioner of the individual making this renewal application for an Authorization to

Possess under the Marihuana Medical Access Regulations and that there have been no changes to the information provided

in the last declaration signed by me.

MEDICAL PRACTITIONER’S SIGNATuRE

DATE

PRINT NAME

R4-B Applicant's Declaration

I declare that I hold a valid Authorization to Possess under the Marihuana Medical Access Regulations and that there

have been no changes to the information provided in my last approved application for an Authorization to Possess and, if

applicable, Application to Obtain Dried Marihuana or Application for Licence to Produce Marihuana.

APPLICANT’S SIGNATuRE

DATE

PRINT NAME

Page 2 of 2

Form R Application For Renewal Of Authorization To Possess Medical Marihuana The Medical Marijuana Mission Page 3