State of Vermont
Department of Public Safety
Instructions: Read ALL the statements below. Once you have read all the statements, initial each statement signifying you
have read and understand the information. If you do not understand any of the statements below, contact the VMR.
______ I understand if my application is approved, my registration is valid for one year and
marijuana may only be used for
______ I understand it is my responsibility to renew annually with the VMR by submitting the required c
with a non-refundable $50 fee to the VMR 30 days before my expiration date to prevent a lapse in status but no more
than 90 days before my expiration date.
______ I understand if I want a person to accom
e to the dispensary AND be present during my appointment in the
dispensing room he or she MUST register as my caregiver with the VMR.
______ I understand a lost or stolen registry identification card MUST be reported to the VMR within 10 business days.
______ I understand the use of marijuana is prohibited;
on the property of a registered dispensary; in any public place, while
operating a motor vehicle, boat, or any other motorized vehicle; in a workplace; operating heavy machinery or
handling a dangerous instrumentality; or that endangers the health or well-being of another person.
______ I understand if my application is denied the decision may be appealed within 7 days and is reviewed based on the
ubmitted with this application and consultation with my Health Care Professional.
______ I understand the amount of marijuana a registered patient and their caregiver co
llectively may possess is no more
than 2 mature marijuana plants, 7 immature plants, and 2 ounces of usable marijuana at the same time.
______ I understand if my application is approved and want to cultivate, I MUST identify a single secure indoor facility on
______ I understand if my application is approved, I may purchase marijua
na and marijuana products, including seeds and
clones from my designated dispensary.
______ I understand if my application is approved, I MUST
y valid registry identification card to dispensary
personnel at an appointment and at the time of delivery.
______ I understand if my application is approved, I may only change my designated dispensary once every 30 days.
______ I understand a Law Enforce
ment Officer is not required to return marijuana or paraphernalia after seizure.
______ I have instructed my registered caregiver(s) or next of kin, in the event of my death, they must notify the VMR within
______ I understand providing fa
lse information on this application or to Law Enforcement may result in criminal penalties.
______ I understand the possession and cultiva
tion of marijuana remains a violation of Federal Law.
______ I understand Vermont Law does not pro
vide protections against Federal Law violations and does not apply to conduct
that occurs outside of the State of Vermont.
______ I understand that my health insurer is not require
d to cover or reimburse the cost of marijuana for symptom relief.