Medical Marijuana Registry Application Form- Alaska

MMRApplicantLetter
Departmentof
HealthandSocialServices
DIVISIONOFPUBLICHEALTH
BureauofVitalStatistics
P.O. Box 110699
Juneau, Alaska 99811-0699
Main: 907.465.5423
Fax: 907.465.3423
DearApplicant:
PerAlaskaStatute17.37.010regardingthemedicalusesofmarijuana,theenclosed
“ApplicationforMedicalMarijuanaRegistry”and“PhysicianStatementmustbecompletedby
theapplicant.Further,ifaprimarycaregiverisspecified,theform“PrimaryCaregiver
ApplicationforMedicalMarijuanaRegistry”mustalsobecompleted.Iftheapplicantalso
specifiesanalternatecaregiver,theform“AlternateCaregiverApplicationforMedical
MarijuanaRegistry”mustbecompleted.
Anonrefundablefee(7AAC34.080(a))of$25.00($20.00forarenewal)andalegible
photocopyoftheAlaskaDriver’sLicenseorAlaskaIdentificationCardoftheapplicantandall
caregiversmustbesubmittedwiththeapplication.Renewalapplicationssubmittedaftera
registryidentificationcardhasexpiredwillbeconsideredanewapplicationandtheapplicant
willberequiredtopaythefeeforfirsttimeapplicants.

Priortomailingyourapplication,reviewittobesurethatallrequiredinformationhasbeen
completed.Ifyourapplicationisnotcomplete,itwillbedeniedandyouwillnotbeallowedto
reapplyforaperiodofsixmonths.Pleasemakeyourcheckormoneyorderpayabletothe
BureauofVitalStatistics;checksmustbepreprintedwithyournameandaddress;andmailthe
checkalongwiththeapplicationtothefollowingaddress:

AlaskaBureauofVitalStatistics
MarijuanaRegistry
P.O.Box110699
Juneau,AK998110699
Youmaywishtouse“ReturnReceiptService”formailingtobesurethatyourapplicationand
feesarereceivedbytheBureau.
Ifyouhave
anyquestionsorconcerns,pleasecontactthemarijuanaregistrysectionofthe
BureauofVitalStatisticsat(907)4655423.
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