Application Form for Registry Identification Card - Michigan

MMP 3501 (Rev. 6/13)
Department of Licensing and Regulatory Affairs
Michigan Medical Marihuana Registry
P.O. Box 30083, Lansing, MI 48909
517-373-0395 ∙ www.michigan.gov/mmp
**APPLICATION FORM**
for Registry Identification Card
For Applicants/Patients 18 years of age or older
PROOF OF MICHIGAN RESIDENCY IS REQUIRED
• Please call our office if you have any questions
• Submit ALL documents in ONE envelope • We recommend the applicant/patient submit the application packet • Type or print legibly
**
APPLICATION PAGE 1 of 2
**
FOR OFFICIAL USE ONLY
Plant possession will default to the Applicant/Patient if neither or both boxes are checked in Section C.
Section C: PERSON ALLOWED TO POSSESS PATIENT’S MARIHUANA PLANTS: (REQUIRED)
SELECT ONLY ONE:
APPLICANT/PATIENT <-------- OR -------->
PRIMARY CAREGIVER
Section A: APPLICANT/PATIENT INFORMATION: (REQUIRED)
For Renewals: Current Card Registry ID Card Number:
P
_________________________________________
Male
Female
Legal Name (First):____________________________________ (MI):______ (Last):______________________________________________
Social Security Number:________________________________________________ Date of Birth:___________________________________
(if applicable)
Mailing Address:_____________________________________________________________________ Apt/Lot #_______________________
City:___________________________________ Zip:_____________ Phone Number (with area code):____________________________________
Alternate Phone Number (with area code):________________________________________________
**A patient who is 18 years of age or older is not required to designate a caregiver**
►To add or change to a new caregiver or retain your current caregiver, you must complete Section B and refer to questions #8-9 on page 2.
►Leave Section B blank ONLY if you are NOT designating a caregiver.
Section B: PRIMARY CAREGIVER INFORMATION: (IF APPLICABLE)
For Renewals: If already registered to this patient, Current Registry ID Card Number:
C
__________________________
Male
Female
Legal Name (First):____________________________________ (MI):______ (Last):______________________________________________
Social Security Number:________________________________________________ Date of Birth:___________________________________
(if applicable)
Mailing Address:_____________________________________________________________________ Apt/Lot #_______________________
City:___________________________________ Zip:_____________ Phone Number
(with area code)
:____________________________________
Alternate Phone Number (with area code):________________________________________________
For Renewals: Check any Changes:
Patient Address Change
Caregiver Address Change
Plant Possession
Patient Adding or Changing to New Caregiver (List the new caregiver’s information in Section B)
Patient Name Change
Caregiver Name Change (Documents required for name changes; see question #2 on page 2)
NEW:
I have never applied before or my registry ID card is expired
RENEWAL:
My current registry ID card is not expired
Page 1/6
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