Medical Marijuana Registry Application Form- Alaska

MedicalMarijuanaRegistryApplicationInstructions
Pleasereadthefollowinginstructionscarefully.Ifyourapplicationisnotcomplete,itmaybe
denied.
Apatientapplyingforamedicalmarijuanaregistryidentificationcardmustprovidetothe
department:
1. Theoriginalcompletedcopyoftheattachedapplicationform(photocopieswillnotbe
accepted)thatincludesthefollowing:
Theapplicant'sname,mailingaddress,physicaladdress,dateofbirth,andAlaska
driver’slicensenumberorAlaskaidentificationcardnumber;
Thename,address,andtelephonenumberofthe patient'sphysician;
Thenameandaddressofthepatient'sprimarycaregiver,ifoneisdesignatedatthe
timeofapplication;and
Theapplicant'ssignature.
2. Iftheapplicantisaminor,anoriginalstatementinwriting(photocopieswillnotbe
accepted)bytheminor'sparentorlegalguardianresidinginAlaska,statingthatthe
parentorguardian:
Consentstoserveastheminor'sprimarycaregiver;and
Givestheparentorguardian'spermissionfortheminortoengageinthemedicaluse
ofmarijuana;
3. Theoriginal,signedformofthephysician’sstatement(photocopiesofthephysician’s
statementwillnotbeaccepted)statingthatthepatienthasbeendiagnosedwitha
qualifying
debilitatingmedicalconditionandtheconclusionofthepatient'sphysician
thatthepatientmightbenefitfromthemedicaluseofmarijuanaoracertifiedcopyof
thatdocumentation;and
4. Theapplicationfeeof$25fortheoriginalrequestor$20feeifitisforatimelyrenewal
(yourcurrentcardhasnotexpired).
5. Mailthisformwithamoneyorderoracheck.Checksmustbepreprintedwithyour
nameandaddress.Thereisa$30.00NSFfeeforreturnedchecks.Pleasemakechecks
payabletotheBureauofVitalStatistics.
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Medical Marijuana Registry Application Form- Alaska PDF

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