Get State Of Illinois Illinois Department Of Public Health Page 3of 4 Printed By Authority Of The State

This guide provides a clear and structured approach to filling out Page 3 of the State Of Illinois Illinois Department Of Public Health application for a Medical Cannabis Registry Identification Card. Follow these steps to ensure accurate completion of the form.

Follow the steps to complete your application accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Review the required sections of the form, including qualifying patient information. Fill in your full name, home address, social security number, and contact details accurately.
3. Complete the gender identification by selecting either ‘Male’ or ‘Female’, and indicate if you are an active duty law enforcement officer, correctional officer, or firefighter if applicable.
4. Fill in the physician information, including name and office address. Ensure this information is current and correctly listed.
5. Select a medical cannabis dispensary from the provided list. It is necessary to choose a dispensary to facilitate the purchase of medical cannabis.
6. Certify the information by signing the signature field for the qualifying patient, and ensure to include the date of your signature.
7. Complete the application fee section by selecting the appropriate fee and preparing your payment. Understand that application fees are non-refundable.
8. Prepare supporting documents as required: proof of age and identity, proof of residency, fingerprint consent form, and any additional documents relevant to reduced fees if applicable.
9. Mail your completed application package to the Illinois Department of Public Health, ensuring it is addressed appropriately to avoid any delays.

Take the next step and complete your application online to access your Medical Cannabis Registry Identification Card.