Medical Marijuana Registry Application Form- Alaska

1 Rev. 06/2013
Application for Medical Marijuana Registry
The appli cation fee is $25 for initial application; or $ 20 f or a renewal appl ic atio n (current card has not ex pir ed).
A photocopy of the Applic ant’s Alaska Driver’s License or Alaska Identificat ion Card must be included with the application.
A witness must be pr esent when the A pplica nt signs and dates the application. The witness must then si gn and d ate the application.
A statement fro m the Applic ant’s physician, u s ing either the physician’s st atement form (page 4) or a lett er addressing th e conditions
mentio ned in the physician’s statem ent form, sign ed by the Applica nt’s physician must be attached.
Mail this f orm with a money order or a check. Checks must be pre printed with your name and address. There is a $30.00 NSF fee for
returned checks. Please m ake checks payable to the Bureau of Vital Statistics.
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Date of Birth (mm/dd/yyyy)
AK Driver’s License/AK ID Number:
If the Applicant is a minor (under the age of 18), please fill out this section:
I, , state that I am the parent or guardian of
(Name of parent or guardian) (Minor applicant’s name)
and that the minor’s physician has explained the possible risks and be nefits of medical use of marijuana to me an d that I consent to
serve as the primary caregiv er for the pati ent and to control the acquisition, possession, dosage, and frequency of use of marijuana by
the minor.
Parent or Guardian Sig nature: Date:
Note: The parent or guardian must also register as the applicant’s pri mary caregiver (page 2).
Physician’s Information:
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Applicant’s Signature:
Date:
Witness’ Printed Name:
Witness’ Signature:
Date:
State Office use only:
Patient #:
Caregiver #: Issue Date: Expiration Date :
Mailto: AlaskaBureauofVitalStatistics
MedicalMarijuanaRegistry
POBox110699
Juneau,AK998110699 PH:9074655423
InitialApplication
Renewal
Page 3/9
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Medical Marijuana Registry Application Form- Alaska PDF

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