Form A Instructions

Form A: Application for Authorization to Possess Marihuana for Medical Purposes

Form A: Cover Page

A1: Applicants information

Indicate whether you are Mrs., Miss, Ms, or Mr. by checking the correct square.
Print your full name: last, first, middle
Put your correct birth date: day, month, and year. (example 07 January 1945)
Print your complete address starting with your house number, street (and state street, avenue). If you have an apartment number, fill it in. If not, leave it blank. Next put your city, province and postal code.
Put a line through the next two lines (lot and concession number)
Fill out your telephone and fax numbers, as well as your email address (if you have them)
Put a check to indicate this is a private residence in the box provided.

A2: Photograph of Applicant

Put a check in the box indicating you have enclosed two copies of a current photograph that clearly identifies you.
Put a check in the box indicating one of these has been signed by the medical practitioner signing the medical declaration, who certifies that it is a true likeness of you.

A3: Appointed Representative

Put a check in the box indicating consent to have us as your representative.
The rest of this section MedMe will fill in.

A4: Proposed Source of Marihuana

Put a check in the box indicating that you plan to have a designated grower and MedMe will fill in the rest.

A5: Authority to Communicate to Canadian Police
There is nothing for you to do here and is self explanatory.

A6: Declarations and Signature