Shangri La Care Cooperative Nonowner Membership Registration Form (Page 2 of 3) in pdf

b. Provided in exchange for services rendered to the Collective;

c. Allocated based on fees that are reasonably calculated to cover overhead costs and operating expenses;

d. Any combination of the above;

11. This Collective is formed in accordance with California Health & Safety Code section 11362.775, as well as under

any and all California state laws that may provide said Collective and its members relief set forth in said statute;

12. That this Collective collectively cultivates medical cannabis for all members, thus it will possess and/or cultivate

enough medical cannabis to meet the aggregate needs of all of its qualified patient members;

13. The information I provided is true and accurate;

14. I did not obtain my recommendation for the use of medical cannabis by fraud or misrepresentation;

15. I am not seeking membership for any fraudulent or law enforcement purpose;

16. I will abide by the Collective’s bylaws, rules and/or guidelines;

17. I agree to that the Collective may use this membership agreement to confirm my membership in the Collective

and to defend the Collective’s legal rights in any court of law;

18. I will not distribute medicine received here to any other person that is not a member of the Collective nor use it for

non-medical purposes;

19. I authorize my recommending physician to verify his or her recommendation or approval for the use of medical

marijuana to the Collective or to law enforcement;

20. I assign to the Collective my right to cultivate medical marijuana for my personal use until such assignment is

revoked in writing by me, and

21. I am acquiring an undivided interest in the medical cannabis cultivated by the Collective on my behalf in an

amount reasonably necessary to meet my current medical needs such that when I receive medical cannabis from

the Collective there is no change in title to the medical cannabis.

[ ] I am Primary Caregiver for registered member _________________________

Executed at ______________________, California.

X_____________________________________________ _______________

New Member Signature

Date

Complete this section only if you already have a medical cannabis ID card issued by a county health department or other

agency pursuant to California Health & Safety Code §11356.7, et seq. (SB-420, 2003).

ID card issued by: _____________________________________________

ID card number: ______________________ Exp. Date: _______________

*Staff Use Only

Recommendation verified by: _____________________________________

Database ID No. _______________ Date of verification ________________

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Shangri La Care Cooperative Nonowner Membership Registration Form Page 2