Transcription of Instructions and Application For Initial Registration As A
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Instructions and Application For Initial Registration As A
Rhode IslandCenter for Professional LicensingRoom 105A - 3 Capitol Hill Providence, RI 02908-5097 Instructions and Application For Initial Registration As APhone: (401) 222-3752 Fax: (401) 222-1745 TTY/TDD: (800) 745-5555 Applicant - Print Name (First/MI/Last)Medical Marijuana Patient**FOR OFFICE USE ONLY** Approved By:Date of Approval: Registration Number: Revised 09/14/2021 jcpDO NOT REMOVE PAGES FROM THE APPLICATIONPLEASE SEND ALL PAGES OF THIS Application WITH PAYMENTIn order to ensure timely delivery and avoid unexpected delays, please send your ORIGINAL completed Application by regular US mail. Photocopies not accepted. ChecklistPatient App. & Fee $ or Fee$ with Proof of Medicaid, SSI, SSDI or Veterans DisabilityProof of RI ResidencyPractitioner FormAutism Diagnosis Form (if applicable)Minor Form (If applicable) Have you EVER held a Registration as a medical marijuana patient in Rhode Island?
GENERAL INFORMATION Please send in all pages of this application together with payment and other required documentation to the address listed on the front cover of this application. Do not separate or mail pages separately. ... Lost Card (s) There is a …
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