Application Form For Registration Form - Michigan Department Of Community Health Page 2
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4Michigan Department of Community Health
Michigan Medical Marihuana Registry
P.O. Box 30083
FOR OFFICIAL USE ONLY
Lansing, MI 48909
APPLICATION FORM FOR REGISTRATION
INSTRUCTIONS:
Please complete all required information to comply with the registration requirements of the
Michigan Medical Marihuana Registry. Attach readable copies of ID and your application fee.
PLEASE TYPE OR PRINT LEGIBLY
APPLICANT INFORMATION: (REQUIRED)
NAME (Last, First, M.I.)
Male
Female
SOCIAL SECURITY NUMBER
DATE OF BIRTH
/
/
/
/
MAILING ADDRESS
PHONE NUMBER
(
)
CITY
STATE
ZIP CODE
EMAIL ADDRESS
(Optional)
MI
Photo Identification: A clear photocopy of one of the following must be attached. Please check appropriate box:
MI Driver’s License #_____________________
MI ID Card #_____________________
Other____________________
PRIMARY CAREGIVER: (IF APPLICABLE)
NAME (Last, First, M.I.)
Male
Female
SOCIAL SECURITY NUMBER
DATE OF BIRTH
/
/
/
/
MAILING ADDRESS
TELEPHONE NUMBER
(
)
CITY
STATE
ZIP CODE
EMAIL ADDRESS
(Optional)
MI
Photo Identification: A clear photocopy of one of the following must be attached. Please check appropriate box:
MI Driver’s License #_____________________
MI ID Card #_____________________
Other____________________
PERSON RESPONSIBLE FOR PATIENT’S MARIHUANA PLANTS: (REQUIRED)
NAME (Last, First, M.I.)
Male
Female
DATE OF BIRTH
/
/
PHYSICIAN INFORMATION: (REQUIRED)
PHYSICIAN’S NAME
MI LICENSE NUMBER
TELEPHONE NUMBER
(
)
REGISTRATION FEE: (REQUIRED)
The registration fee is $100.00 ($25.00 if enrolled in Medicaid Health Plan or receiving SSI). Enclose your
check or money order made payable to State of Michigan—MMMP. We do not accept Credit or Debit Cards.
Attach proof/verification/documentation of your Medicaid or SSI eligibility.
SIGNATURE & DATE: (REQUIRED)
I ATTEST THAT THE ABOVE INFORMATION IS TRUE.
I UNDERSTAND THAT LAW ENFORCEMENT PERSONNEL CAN VERIFY THE VALIDITY OF MY REGISTRATION
NUMBER ONLY.
I AUTHORIZE THE RELEASE OF MY NAME AND DATE OF BIRTH TO CONFIRM IDENTITY ONLY IF A VALID
REGISTRATION NUMBER HAS BEEN PROVIDED BY LAW ENFORCEMENT PERSONNEL.
I DO NOT AUTHORIZE THE RELEASE OF ANYTHING BUT THE STATUS OF MY REGISTRATION NUMBER.
__________________________________________________________________________
_____________________
Applicant’s Signature
Date
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