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APPLICATION FORM
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APPLICATION FORM
APPLICATION FORM
Cathy
2016-11-10T15:46:16-08:00
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?
Please Select
Current Patient
Google
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East Bay Express
420 MD
Our Website
Other
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?
*
Please Select
Patient
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