Form R Instructions

Form R: Renewal

Make an appointment with your doctor. You may want to bring a copy of the Medical Practitioner Release Form.

R1: Applicant's 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 line through the next two lines (lot and concession number)

R2: Source of Marihuana

Check the third box indicating that you plan to have a designated person grow marihuana for you

R3: Information on Medical Practitioner

R4-A: Medical Practitioner's Declaration and Signature

R4-B: Applicant's Declaration