Medical Cannabis Caregiver Registration - Illinois Department Page 2
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4State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for a Designated Caregiver Registry Identification Card
Proof of residency
Attach a copy of any two of the following items:
Pay stub or electronic deposit receipt issued less than 60 days prior to the application that shows
evidence of the applicant’s withholding for state income tax.
Valid voter registration card with an address in Illinois.
A valid, unexpired Illinois driver’s license or other state identification card issued by the Illinois secretary
of state.
Notarized homeless status certification:
https://
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If you are using this form, you only need this document to prove residency.
Bank statement, dated less than 60 days prior to application.
Deed/title, mortgage, rental/lease agreement.
Insurance policy (homeowner’s or renter’s).
Medical claim or statement of benefits (from private insurance company or government agency), dated
less than 90 days prior to application); Social Security Disability Insurance Statement; or Supplemental
Security Income Benefits Statement.
Tuition invoice/official mail from college or university, dated less than 12 months prior to application.
Utility bill, including, but not limited to, those for electric, water, refuse, telephone land-line, cable or gas,
issued less than 60 days prior to application.
Proof of identity and age
Attach one clear color photocopy of a U.S. or Illinois government-issued photo ID
Photograph
Attach a photograph that:
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was taken less than 30 days before application submission;
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was taken against a plain background or backdrop;
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is in natural color;
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was taken in full-face view directly facing the camera with a neutral facial expression and both eyes open
(prescription glasses and religious head coverings not covering any areas of the open face are allowed);
•
is at least 2 inches by 2 inches in size; and
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is at least 600 x 600 pixels, but no greater than 1,200 x 1,200 pixels in dimension.
Uniform Conviction Information Act (UCIA) Fingerprint Consent
Submit a copy of the UCIA fingerprint consent form. You may obtain a current listing of
live scan fingerprint vendors from the Illinois Department of Financial and Professional Regulation website at
https:// Contact the live scan fingerprint vendor before going to
get your fingerprints taken. When you go to get your fingerprints taken, remember to bring the UCIA Fingerprint
Consent Form. Once you have your fingerprints taken, the UCIA Fingerprint Consent Form must be returned to
the Department’s Division of Medical Cannabis along with the completed patient application.
Application Fee
Include payment of $25 by check, money order or credit card (online applicants only) payable to:
Illinois Department of Public Health
Page 2 of 2
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