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, and 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 commercial marijuana which I require to treat my medical condition/disease.

Dated:                                                                                                  

Signature:                                                                                                  


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:___________________________________________________

 

                   MUST BE AN ORIGINAL COPY WITH NOTARY STAMP ON EACH PROVIDER / CARE GIVER FORM
                       NO PHOTO COPIES OF THE ORIGINALS ARE ACCEPTED AS "AUTHENTICATED COPIES"