MEDICAL MARIJUANA PROVIDER FORM



1.  My name is: ___________________________________________________
                             (insert full name)                                                                                   

My mailing address is:___________________________________________________
                                           (insert full address)                                                                              

2.  I suffer from:

      ONE OF THE DESIGNATED MEDICAL PROBLEMS OUTLINED IN THE
MEDICAL MARIJUANA LAW OF THE STATE OF MAINE 22 M.R.S.A. 2383-B

and use marijuana to ease, control, and relieve the symptoms of my medical disease/condition.

3.  In order to procure my marijuana, I need to either grow it or buy it from someone, which is a problem and a danger to me. I am concerned that I won't be able to grow enough or find enough marijuana to buy for my needs, so I need someone to help me to do this.

4.  I hereby nominate, appoint, and constitute________________________________________________________as my medical marijuana provider for the sole purpose of assisting me with the growing of marijuana, and/or growing marijuana for my use, and/or supplying me with the marijuana which I require to treat my medical condition/disease.

Dated: ___________________________________________                                                                                                 

Name:____________________________________________                                                                                                  

Personally appeared the above-named.  Before me on the date above-written and acknowledged his/her signature and the above stated facts as true to the best of his/her knowledge.

_____________________________________________________
                                                          (Notary Public/Attorney at Law) 

My commission expires:__________________