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State of Illinois
Illinois Department of Public Health
Printed by Authority of the State of Illinois
IOCI 20-446
CG
State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Patient Program
Application for a Designated Caregiver Registry Identification Card
***Do not use this form for Terminal Illness***
APPLICATION TYPE (Check the appropriate answer)
New: I have never had an Illinois Medical Cannabis Designated Caregiver Registry Identification Card.
New with Current Patient: I have never had an Illinois Medical Cannabis Designated Caregiver Registry
Identification Card, but I am applying to be a caregiver for a patient who has already been approved.
CAREGIVER INFORMATION
QUALIFYING PATIENT INFORMATION
First Name Middle Name Last Name
Home Address
Apartment or Suite # City State
IL
ZIP Code
Telephone Number (###-###-####) E-mail Address
Date of Birth (mm/dd/yyyy) Gender
Male Female
Social Security Number (###-##-####) Driver’s License Number Driver’s License State No Driver’s License
First Name Middle Name Last Name
Home Address Apartment or Suite Number
City County State
IL
ZIP Code
Telephone Number (###-###-####) E-mail Address
Date of Birth (mm/dd/yyyy) Gender
Male Female
_____________________________________________________________ ____________________________
SIGNATURE of Qualifying Patient DATE (mm/dd/yyyy)
This application was prepared by:
_____________________________________________________________ ____________________________
PRINT/TYPE PREPARER’S NAME DATE (mm/dd/yyyy)
_____________________________________________________________ ____________________________
FIRM OR ORGANIZATION NAME PHONE NUMBER
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State of Illinois
Illinois Department of Public Health
Printed by Authority of the State of Illinois
IOCI 20-446
CG
State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Patient Program
Application for a Designated Caregiver Registry Identification Card
ATTESTATIONS
I certify the information provided in this application is true and accurate to the best of my knowledge.
Submission of false, misleading, or inaccurate information in connection with this application is grounds for revocation of my
Illinois Medical Cannabis Designated Caregiver Registry Identification Card and other administrative, civil or criminal penalties.
I additionally certify that I have been given actual Notice and understand that, notwithstanding the Compassionate
Use of Medical
Cannabis Patient Program Act (Act):
(i) cannabis is a prohibited Schedule I controlled substance under federal law;
(ii) participation in the program is permitted only to the extent provided by the strict requirements of the Act;
(iii) any activity not sanctioned by the Act may be a violation of state or federal law and could result in arrest, conviction, or
incarceration;
(iv) growing, distributing, or possessing cannabis under the Act, unless done through a federally-approved research program, is a
violation of federal law;
(v) growing, distributing, or possessing cannabis in any capacity, except through a federally-approved research program, may
be a violation of state or federal law and could result in arrest, conviction or incarceration;
(vi) use of medical cannabis, or possessing a medical cannabis patient or caregiver registry card, may affect an individual’s
ability to receive or retain federal or state licensure in other areas;
(vii) use of medical cannabis or possessing a medical cannabis patient or caregiver registry card, in tandem with other conduct,
may be a violation of state or federal law and could result in arrest, conviction or incarceration;
(viii) participation in the Medical Cannabis Patient Program does not authorize any person to violate federal law or state law,
(ix) the Act does not provide any immunity from or affirmative defense to arrest or prosecution under federal law or state law, other
than as set out in 410 ILCS 130/25; and
(x) applicants shall indemnify, hold harmless, and defend the state of Illinois for any and all civil or criminal penalties resulting
from participation in the program.
_____________________________________________________________ ____________________________
SIGNATURE DATE (mm/dd/yyyy)
APPLICATION FEES
Provide a check or money order payable to Illinois Department of Public Health.
Choose One:
APPLICATION FEES ARE NOT REFUNDABLE
Application Fee for Designated Caregiver
$25 – One-Year Registry Card
$50 – Two-Year Registry Card
$75 – Three-Year Registry Card
$75 – Caregiver applying separately for a patient who has already been registered
(the expiration date for the caregiver and the patient card will be the same)
Page 3 of 3
State of Illinois
Illinois Department of Public Health
Printed by Authority of the State of Illinois
IOCI 20-446
CG
State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Patient Program
Application for a Designated Caregiver Registry Identification Card
REQUIRED DOCUMENTS
Place the following items in an envelope or upload in the electronic application:
Non-refundable application fee (Check or Money Order to Illinois Department of Public Health)
Photograph
Taken in the last 30 days
Taken against a plain, white or off-white background or backdrop
In natural color (Do not use a filter)
Full-face view directly facing the camera with a neutral facial expression and both eyes open
At least 2 inches by 2 inches in size
It is recommended you use a passport photo vendor to ensure the photograph meets these requirements.
Contact the Division of Medical Cannabis if a photograph is in violation of or contradictory to the qualifying patient’s religious
convictions.
Proof of age and identity
Submit a clear, color copy of an Illinois Driver’s License, Illinois State ID, or the photograph page of a US passport.
Proof of residency
If your Driver’s License, Temporary Visitor Driver's License or State ID address matches your application submit one additional
proof of residency. If you submit a US Passport as your proof of identity or your Driver’s License or State ID address does not
match the address on your application, submit two of the following:
Pay stub or electronic deposit receipt, issued less than 60 days prior to the application date, that shows evidence of
withholding for State income tax
Valid voter registration card with an address in Illinois
Bank statement (dated less than 90 days prior to application) or credit card statement (dated less than 60 days prior to
application);
Deed/title, mortgage or rental/lease agreement; property tax bill;
Insurance policy (current coverage for automobile, homeowner's, health or medical, or renter's);
Medical claim or statement of benefits (from a hospital or health clinic, private insurance company or public (government)
agency, dated less than 12 months prior to application)
Tuition invoice/official mail from college or university, dated less than the 12 months prior to application
Utility bill, including, but not limited to, those for electric, water, refuse, telephone land-line, cellular phone, cable or gas,
issued less than 60 days prior to application
W-2 from the most recent tax year
Proof of residency must include name and address and match the address on the application
Mail the application and required documents to:
Illinois Department of Public Health
Division of Medical Cannabis
535 West Jefferson Street
Springfield, Illinois 62761-0001
Questions? Contact the Division of Medical Cannabis at 855-636-3688 or
DPH.MedicalCannabis@Illinois.gov.