Form Mmp 3502a - Caregiver Change Form Page 2

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MMP 3502A (Rev. 1/15)

Office Use Only

(517)284-6400

Michigan Medical Marihuana Program

Caregiver Change Form

(Required)

Caregiver Information – As it appears on your current registry ID card.

Caregiver Registry ID Card Number

Date of Birth

Telephone Number

Suffix ( Jr., Sr., III., etc.)

Legal First Name

Middle Initial

Legal Last Name

Caregiver Name Change

☐

Legal First Name

Middle Initial

Legal Last Name

Suffix

Caregiver Address Change

☐

Mailing Address

Apartment/Suite/Lot #

City

State

Zip Code

Remove Current Patient(s)

☐

1. Name of current Patient:

2. Name of current Patient:

3. Name of current Patient:

4. Name of current Patient:

5. Name of current Patient:

Request Replacement Caregiver Card(s)

☐

1. Card Registry ID number or Patient Name:

2. Card Registry ID number or Patient Name:

3. Card Registry ID number or Patient Name:

4. Card Registry ID number or Patient Name:

5. Card Registry ID number or Patient Name:

(Required)

Caregiver Signature & Declaration

I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated Law 1

of 2008, MCL 333.26421 et seq.), Administrative Rules and amendments thereafter. I understand that a false or fraudulent statement, with the intent to aid,

abet, or assist in defrauding the state is guilty of perjury punishable in the manner provided by law.

Signature of Caregiver:

Date:

_______________________

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