Medical Marijuana Registry Application Form- Alaska

3 Rev. 06/2013
Alternate Caregiver Application for
Medical Marijuana Registry
Please note that an Alternate Caregiver is not required for an Applica n t to be approved for the Medical Marijuana Registry. This
form is compl eted if the Applicant wishes to have both a Primary Car egive r and an Altern ate Car egive r.
A photocopy of the Alternate Caregiver’s Alaska Driver’s License or Alaska Identification Card must be included with this
application.
A witness must be present when the Alternate Caregiver signs and dates the application. The witness must then sign
and date the application.
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:
Check all that apply.
I am at least 21 years of age;
I have never been convicted of a felony offense under AS 11.71 or AS 11.73 or a law or ordinance of
another jurisdiction with elements similar to an offense under AS 11.71 or AS 11.73;
I am not currently on probation or parole from this or another jurisdiction.
I certify under penalty of perjury that the foregoing is true.
Alternate Caregiver’s
Signature:
Date:
Witness’ Printed Name:
Witness’ Signature:
Date:
Page 5/9
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Medical Marijuana Registry Application Form- Alaska PDF

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