Form Oha 9240 - Oregon Medical Marijuana Program Application
Download a blank fillable Form Oha 9240 - Oregon Medical Marijuana Program Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Oha 9240 - Oregon Medical Marijuana Program Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Print
Reset
PUBLIC HEALTH DIVISION
Oregon Medical Marijuana Program
Oregon Medical Marijuana Program Application
(to be completed by patient)
Please read instructions and fee information on back BEFORE filling out form
Patient information (required; type or print legibly)
Name (first, middle initial, last):
Date of birth:
/
/
Mailing address:
Gender:
M
F
City:
State:
ZIP:
County:
Phone number:
Proof of Oregon residency (check one and enclose a copy):
Oregon ID OR
Other ID and residency proof
Government-issued photo ID number (enclose a copy):
Caregiver information (complete only if you have a caregiver; patients under age 18 must name a caregiver)
Name (first, middle initial, last):
Date of birth:
/
/
Mailing address:
Gender:
M
F
City:
State:
ZIP:
County:
Phone number:
Government-issued photo ID number (enclose a copy):
Grower information (complete this and the grow site section only if you are your own grower or designating a grower)
Name (first, middle initial, last):
Date of birth:
/
/
Mailing address:
Gender:
M
F
City:
State:
ZIP:
County:
Phone number:
Government-issued photo ID number (enclose a copy):
Grow site information (complete this and the grower section only if you have a grower/grow site)
Physical grow site address:
City:
State: OR
ZIP:
County:
Grow site address zoning (check one and enclose a copy if requested):
Outside city limits
Within city limits (enclose address zoning documentation)
Grower reporting and grow site registration fee requirements (complete if you have a grower/grow site).
Failure to check one or more of the following boxes will result in your application being INCOMPLETE.
I designated a grower and it is not me.
My grow site is not my residence.
The grower (even if it is you) will be transferring medical marijuana to a dispensary or processing site.
My grow site has more than 12 mature medical marijuana plants.
If you checked one or more of the above boxes, the grower (even if it is you) will be required to register online, submit monthly
reports to the OMMP and pay the grow site registration fee. If none are true, you MUST check the box below.
None of the above statements are true.
Patient signature (required) — I testify the above information is true and I understand my application or cards may be
denied, suspended or revoked for submitting false information.
Patient signature:
Date:
1
OHA 9240 (5/2017)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal