Registration Application

Customer Details:

Full Name*

First NameLast Name

Date of Birth*

Date

Are you registering as a veteran*

YesNo

If your answer to the previous was yes, please enter your K number here

Gender*

FemaleMaleOther

Phone Number*

E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is this Registration for Interim Supply*

YesNo

Residence Type*

Private HomeApartmentBusinessOther

Shipping Address If different than Primary Address

Mailing Address If different than Primary Address

Caregiver Details (If not Applicable Enter NA)*

The undersigned applicant or person responsible hereby agrees and warrants that: 1) Applicant ordinarily resides in Canada: 2) The original medical document accompanies this application: 3) The applicant understands and acknowledges that any medical documents sent with this form cannot be returned once registration is complete: 4) The medical document/registration certificate is not being used to seek or obtain fresh or dried marijuana and/or cannabis oil from another source: 5) The information in the original application and medical document/registration certificate is correct and complete: 6) The application will use fresh or dried marijuana and/or cannabis oil only for his or her own medical purposes: 7) The Applicant understand and acknowledges that medicinal marijuana is not currently approved for use as a drug in Canada and that its safety and risks have not been fully studied and the appropriate dosage is unclear: 8) The Applicant acknowledges and agrees that he or she is using any medicinal marijuana product obtained by 1809 Underground at his or her own risk, and releases 189 Underground (and its partners, providers, officers, directors and staff) from any and all actions, claims, complaints and demands for damages, loss of injury whatsoever arising directly or indirectly from the use of medicinal marijuana obtained from 1809 Underground: 9) The applicant consents to the healthcare practitioner named in this document disclosing required personal health information to 1809 Underground for the purposes of complying with the requirements of the access to cannabis for medical purposes regulations (ACMPR). The applicant understands and agrees that a copy of this consent and registration application may be provided to the healthcare practitioner named herein.

I agree