Medical Cannabis Caregiver Registration - Illinois Department Page 3
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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
NEW APPLICATION OR RENEWAL (Check the appropriate answer)
New: I have never had an Illinois Medical Cannabis Designated Caregiver Registry Identification Card.
Renewal: I have had an Illinois Medical Cannabis Designated Caregiver Registry Identification Card.
My Designated Caregiver Registry Identification Card Number is ________________________.
CAREGIVER INFORMATION
Social Security Number (### - ## - ####)
Drivers License # (if applicable):
Driver’s License State (if applicable):
First Name
Middle Name
Last Name
Home Address
Apartment or Suite #
City
State
ZIP Code
IL
Telephone Number (###-###-####)
E-mail Address (required for online applicants)
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
QUALIFYING PATIENT INFORMATION
Drivers License # (if applicable):
Driver’s License State (if applicable):
First Name
Middle Name
Last Name
Home Address
Apartment or Suite #
City
State
ZIP Code
IL
Telephone Number (###-###-####)
E-mail Address (required for online applicants)
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
_____________________________________________________________
____________________________
SIGNATURE of Qualifying Patient
DATE (mm/dd/yyyy)
Page 1 of 2
Printed by Authority of the State of Illinois
IOCI 15-164
P.O.#3115002
2M
9/14
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