Professional Documents
Culture Documents
Department of
Health and Social Services
DIVISION OF PUBLIC HEALTH
Bureau of Vital Statistics
P.O. Box 110699
J uneau, Alaska 99811-0699
Main: 907.465.5423
Fax: 907.465.3423
DearApplicant:
PerAlaskaStatute17.37.010regardingthemedicalusesofmarijuana,theenclosed
ApplicationforMedicalMarijuanaRegistryandPhysicianStatementmustbecompletedby
theapplicant.Further,ifaprimarycaregiverisspecified,theformPrimaryCaregiver
ApplicationforMedicalMarijuanaRegistrymustalsobecompleted.Iftheapplicantalso
specifiesanalternatecaregiver,theformAlternateCaregiverApplicationforMedical
MarijuanaRegistrymustbecompleted.
Anonrefundablefee(7AAC34.070(b))of$25.00($20.00forarenewal)andalegible
photocopyoftheAlaskaDriversLicenseorAlaskaIdentificationCardoftheapplicantandall
caregiversmustbesubmittedwiththeapplication.Renewalapplicationssubmittedaftera
registryidentificationcardhasexpiredwillbeconsideredanewapplicationandtheapplicant
willberequiredtopaythefeeforfirsttimeapplicants.
Priortomailingyourapplication,reviewittobesurethatallrequiredinformationhasbeen
completed.Ifyourapplicationisnotcomplete,itwillbedeniedandyouwillnotbeallowedto
reapplyforaperiodofsixmonths.Pleasemakeyourcheckormoneyorderpayabletothe
BureauofVitalStatistics;checksmustbepreprintedwithyournameandaddress;andmailthe
checkalongwiththeapplicationtothefollowingaddress:
AlaskaBureauofVitalStatistics
MarijuanaRegistry
P.O.Box110699
Juneau,AK998110699
YoumaywishtouseReturnReceiptServiceformailingtobesurethatyourapplicationand
feesarereceivedbytheBureau.
Ifyouhaveanyquestionsorconcerns,pleasecontactthemarijuanaregistrysectionofthe
BureauofVitalStatisticsat(907)4655423.
MedicalMarijuanaRegistryApplicationInstructions
Pleasereadthefollowinginstructionscarefully.Ifyourapplicationisnotcomplete,itmaybe
denied.
Apatientapplyingforamedicalmarijuanaregistryidentificationcardmustprovidetothe
department:
1. Theoriginalcompletedcopyoftheattachedapplicationform(photocopieswillnotbe
accepted)thatincludesthefollowing:
Theapplicant'sname,mailingaddress,physicaladdress,dateofbirth,andAlaska
driverslicensenumberorAlaskaidentificationcardnumber;
Thename,address,andtelephonenumberofthepatient'sphysician;
Thenameandaddressofthepatient'sprimarycaregiver,ifoneisdesignatedatthe
timeofapplication;and
Theapplicant'ssignature.
2. Iftheapplicantisaminor,anoriginalstatementinwriting(photocopieswillnotbe
accepted)bytheminor'sparentorlegalguardianresidinginAlaska,statingthatthe
parentorguardian:
Consentstoserveastheminor'sprimarycaregiver;and
Givestheparentorguardian'spermissionfortheminortoengageinthemedicaluse
ofmarijuana;
3. Theoriginal,signedformofthephysiciansstatement(photocopiesofthephysicians
statementwillnotbeaccepted)statingthatthepatienthasbeendiagnosedwitha
qualifyingdebilitatingmedicalconditionandtheconclusionofthepatient'sphysician
thatthepatientmightbenefitfromthemedicaluseofmarijuanaoracertifiedcopyof
thatdocumentation;and
4. Theapplicationfeeof$25fortheoriginalrequestor$20feeifitisforatimelyrenewal
(yourcurrentcardhasnotexpired).
5. Mailthisformwithamoneyorderoracheck.Checksmustbepreprintedwithyour
nameandaddress.Thereisa$30.00NSFfeeforreturnedchecks.Pleasemakechecks
payabletotheBureauofVitalStatistics.
1 Rev. 06/2013
Primary Caregiver Application for
Medical Marijuana Registry
Please note that a Primary Caregiver is not required for an Applicant to be approved for the Medical Marijuana Registry.
A photocopy of the Primary Caregivers Alaska Drivers License or Alaska Identification Card must be included with this
application.
A witness must be present when the Primary Caregiver signs and dates the application. The witness must then sign and
date the application.
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Date of Birth (mm/dd/yyyy)
AK Drivers License/AK ID Number:
Check all that apply.
I am at least 21 years of age;
I have never been convicted of a felony offense under AS 11.71 or AS 11.73 or a law or ordinance of
another jurisdiction with elements similar to an offense under AS 11.71 or AS 11.73;
I am not currently on probation or parole from this or another jurisdiction.
I certify under penalty of perjury that the foregoing is true.
Primary Caregivers
Signature:
Date:
Witness Printed Name:
Witness Signature:
Date:
3 Rev. 06/2013
Alternate Caregiver Application for
Medical Marijuana Registry
Please note that an Alternate Caregiver is not required for an Applicant to be approved for the Medical Marijuana Registry. This
form is completed if the Applicant wishes to have both a Primary Caregiver and an Alternate Caregiver.
A photocopy of the Alternate Caregivers Alaska Drivers License or Alaska Identification Card must be included with this
application.
A witness must be present when the Alternate Caregiver signs and dates the application. The witness must then sign
and date the application.
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Date of Birth (mm/dd/yyyy)
AK Drivers License/AK ID Number:
Check all that apply.
I am at least 21 years of age;
I have never been convicted of a felony offense under AS 11.71 or AS 11.73 or a law or ordinance of
another jurisdiction with elements similar to an offense under AS 11.71 or AS 11.73;
I am not currently on probation or parole from this or another jurisdiction.
I certify under penalty of perjury that the foregoing is true.
Alternate Caregivers
Signature:
Date:
Witness Printed Name:
Witness Signature:
Date:
4 Rev. 06/2013