Nevada Medical Marijuana Registry
Application Request
Instructions
Complete this form. Send completed form to the address below. Include copies of the front and back of the
patient’s driver’s license or State ID. If there is a caregiver, also include copies of the front and back of the
caregiver’s driver’s license or State ID.
Applicant
NAME (First, Middle, Last) DATE OF BIRTH
PHYSICAL ADDRESS (Address on the Driver’s License or State ID) MOBILE PHONE NUMBER
PHYSICAL CITY, STATE ZIPCODE HOME PHONE NUMBER
MAILING ADDRESS (If different from above address) SOCIAL SECURITY NUMBER
MAILING CITY, STATE ZIPCODE NEVADA DRIVER’S LICENSE OR STATE ID NUMBER
EMAIL GENDER
MALE
FEMALE
MINOR RELEASE
THE PATIENT IS A MINOR
CAREGIVER
I WILL HAVE A CAREGIVER
Caregiver (complete if you will have a caregiver)
NAME (First, Middle, Last) DATE OF BIRTH
PHYSICAL ADDRESS (Address on the Driver’s License or State ID) MOBILE PHONE NUMBER
PHYSICAL CITY, STATE ZIPCODE HOME PHONE NUMBER
MAILING ADDRESS (If different from above address) SOCIAL SECURITY NUMBER
MAILING CITY, STATE ZIPCODE NEVADA DRIVER’S LICENSE OR STATE ID NUMBER
EMAIL GENDER
MALE
FEMALE
20151204
Include this invoice with your driver’s license copies and mail to the address to the right.
Division of Public and Behavioral Health
Medical Marijuana Registry
4150 Technology Way, Suite 101
Carson City, NV 89706
Mail
