APPLICATION FORM

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone (10 digits)*
Email*
Date of Birth*
MM
DD
YYYY
Form of ID*
- Government Issued ID
- Driver's License
- Passport
ID / License #*
Expiration Date*
MM
DD
YYYY
How Did You Hear About Us?
How Else Did You Hear About Us?
Upload All Required Supporting Documents Here*
Drop files here or

Accepted file types: jpg, png, pdf, jpeg.
Valid recommendation note and picture ID (US Driver’s License, Gov't ID or Passport)
Patient or Caregiver?*
Caregivers must bring patient’s designated caregiver’s paperwork, as well as a government issued I.D. for themselves as well as the patient they represent. (Notarized copy is acceptable)"
*
Read the rules of the PCC
- I have read and agree to uphold the rules of the PCC
- I authorize my recommending physician to verify his or her recommendation or approval for the use of medical cannabis
- I declare under the Penalty of Perjury under the laws of the State of California (1) The information I provide to PCC is true and correct, and (2) I am not obtaining membership for fraudulent purposes.
Signature*
Please sign your name in the above field. This will be considered your legal signature when form is submitted.

The Information on this form will be kept confidential