Address: _________________________________________________________
City: _________________ Prov: ________Postal: __________________
Home: _______________ Work: __________________ Cell: _____________
e-mail:__________________________________________
HEALTH CANADA
License Number
I consent to the release of my medical information to T.I.M.E.
I agree to provide a copy of my Health Canada Medical Marihuana Licence CARD and
Form MMAD-03066-07 - Authorization to Possess Dried Marihuana for Medical Purposes
Please include them with this form
I agree to abide by the rules and regulations of T.I.M.E.
Purchases are for medical purposes only
Resale and/or redistribution will result in immediate revocation of patient status
Yes / No I authorize T.I.M.E. as my designated grower
Applicant Signature _____________________________
If you are a legal caregiver please provide your information on your driver’s license or health card.
Name: ________________________________
Address: ________________________________
________________________________
___________________________
Caregivers Signature