Patient Med & Rec Registration

Recreational And Medical Cannabis Consumer Registration Form

Licenced State Dispensary Notice: Office Of Cannabis Management

Due to the new state regulation on dispensaries all customer who purchase cannabis products from any dispensary are required to pay a refundable state registration fee.The fee is required to confirm if you are the owner of the state ID or Drivers License which you provide during the registration process. The state fee is refundable upon delivery in cash by the delivery agent in charge of your package.

Name

Date of Birth

Phone Number

Home Address

Have your ever use cannabis? *

Which dispensaries have you visited in your state? *

IF Yes, How often? *

What do you use cannabis for? *

Are you a veteran of the Armed Service? *

Upload front photo of your state ID or Drivers License *

No file chosen Upload Back photo of your state ID or Drivers License *

Half passport size photo of your self *

Refundable State Registration Fee $299.99