Cannabis Registry Agency Form 2023

Complete this form for an appointment
Exactly As It's Written on Your Driver's License/State ID*

First NameMiddle NameLast Name
DATE OF BIRTH*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL ADDRESS: REQUIRED IF USING EXPRESS SERVICE
MMP CARD STATUS:*

I CURRENTLY HAVE A VALID MMP CARDMY MMP CARD IS EXPIREDTHIS IS MY FIRST MMP CARD
WHY DO YOU WANT TO USE MEDICAL MARIJUANA?*
SECTION B: PERSON ALLOWED TO POSSESS PLANTS*

I AM MY OWN CAREGIVERI HAVE A CAREGIVER/NOT MYSELF
CAREGIVER INFORMATION: FULL NAME, DOB, ADDRESS, PHONE, EMAIL
SELECT APPOINTMENT DAY*

MONDAY: APRIL 3rd, 2023. Calling begins at 3pm.TUESDAY: APRIL 4th, 2023. Calling begins at 3pmWEDNESDAY: MARCH 29th, 2023. Calling begins at 3pmTHURSDAY: MARCH 30th, 2023. Calling begins at 3pmFRIDAY: MARCH 31st, 2023. Calling begins at 12 noon.
SELECT YOUR SERVICE: EXPRESS SERVICE IS 72 HOURS TURN AROUND.*

$125 EXPRESS SERVICE: We take care ovf EVERYTHING.$70 SELF-SERVICE: You submit your application and pay an addition $40 to LARA.$100 FOR MINORS ONLY, required TWO DOCTORS.
TEXT A COPY OF YOUR DRIVER'S LICENSE AND MMP CARD TO:

(616) 719-0441
Please verify that you are human*
Should be Empty:

Complete this form for an appointment