Form E1 Instructions

Form E1: Application to Obtain Dried Marihuana 

Form E1 Cover Page

• Check the first box indicating that you are applying for MMAR authorization

E1-1: Applicants Information

• Indicate whether you are Mrs., Miss, Ms, or Mr. by checking the correct square.
• Print your full name: first, middle and last
• Print 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.
• Print your home phone number, Fax or E-mail address

E1-3: Delivery Instructions

• Put a check in the first box if you want to have product shipped to your address
• Put a check in the second box to have your doctor receive the medicine.  You will need to provide the doctor's address.

E1-4: Declaration and Signature

• You will need to sign your name in full, print today's date
• Print your full name