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Application for Authorization to Possess Dried Marihuana - Form A

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Form A - Application for Authorization to Possess Marihuana for Medical Purposes

Authorizations are permitted for a period of no more than 12 months. This form is to be used to apply for:

  • an original authorization

OR

  • renewal of an authorization if changes since your last renewal or amendment

Note: For authorized persons who are applying to renew their authorization, if there have been no changes since last year, Short Form A - Renewal can be used instead of Form A .

Important

  1. It is important to understand that all information requested must be provided to avoid unnecessary delays.
  2. We cannot process the application until all appropriate forms are received.
  3. Please retain a photocopy of this form for your files.

If you have any questions regarding this form, please contact Health Canada toll-free at 1-866-337-7705.

Please forward all completed applications to:
Marihuana Medical Access Division
Drug Strategy and Controlled Substances Programme
Health Canada
Address Locator: 3503B
Ottawa, ON K1A 1B9

A1 Applicant's Information

  • Mrs.
  • Miss.
  • Ms.
  • Mr.
  • Applicant 's full name:
    • last
    • first
    • middle
  • Date of Birth:
    • day
    • month
    • year
  • Address:
    • Apartment Number:
    • City:
    • Province:
    • Postal Code:
  • If no street address is available, please provide lot and concession number:
    • Lot Number:
    • Concession Number:
  • Telephone: ()
  • Fax: ()
  • E-mail:
  • This address is:
    • A private residence (E.G.,House or apt.) or
    • Not a private residence (E.G.,Hospice,Hospital,Etc.)
  • Name of residence:
  • Mailing Address (if different from above):
    • Address or P.O.Box:
    • Apartment Number:
    • City:
    • Province:
    • Postal Code:

A2 Photograph of Applicant

  • I have enclosed two copies of a current photograph that clearly identifies me.
  • The back of one of the photographs has been signed by the medical practitioner signing the medical declaration, who certifies that it is a true likeness of me.

IMPORTANT: A standard passport photograph is preferred but if one is not available,the photograph submitted must meet the following standards:

  • It must show you alone in the photograph.
  • It must show a full frontal view of your head and shoulders against a plain contrasting background.
  • It must be at least 43 mm × 54 mm (1 11/16 inches × 2 1/8 inches) and not more than 50 mm × 70 mm (2 inches × 2 3 /4 inches), and have a view of your head that is at least 30 mm (1.375 inches) in length.
  • It must reveal your face without sunglasses or any other obstructions. Facial hair is permitted, of course.

Note: This section does not need to be completed if a photograph has been provided within the last 5 years.

A3 Appointed Representative

This section is optional

You may appoint a representative to speak to Health Canada on your behalf. Health Canada will be authorized to exchange information about your case -- including personal data and material contained in your medical records -- with an appointed representative that you choose (for example, a family member or a friend).

Should you not provide this consent, Health Canada will communicate only with and through you.

You may withdraw the appointment of your representative at any time.

Appointed representative (optional):

  • I consent to allowing Health Canada to exchange personal and medical information about my case with my appointed representative.
  • Mrs.
  • Miss
  • Ms.
  • Mr.
  • Representative 's full name:
    • last
    • first
    • middle
  • Mailing Address:
    • Apartment Number:
    • City:
    • Province:
    • Postal Code:
  • Telephone: ()
  • Fax: ()
  • E-mail:

A4 Proposed Source of Marihuana

You are required to indicate your proposed source of marihuana by choosing one of the following:

  • I plan to produce my own marihuana.

You must apply to get licence to grow your own plants and you must fill out
Form C: Application for Licence to Produce Marihuana by Applicant.

To purchase seeds from Health Canada so you can grow your own plants, you must fill out Form E2: Application to Obtain Marihuana Seeds.

OR

  • I plan to have a designated person grow the marihuana for me.
    My designated person will be:

You must apply to get a licence for someone to grow plants for you and you must fill out Form D: Application for Licence to Produce Marihuana by a Designated Person .

To purchase seeds from Health Canada so someone can grow plants for you, you must fill out Form E2:Application to Obtain Marihuana Seeds.

OR

  • I plan to purchase dried marihuana from Health Canada.
    To purchase a supply of dried marihuana from Health Canada,you must fill out
    Form E1:Application to Obtain Dried Marihuana.

A5 Authority to Communicate to Canadian Police

To reduce the possibility of police intervention when you engage in activities allowed under your authorization or licence, if asked, Health Canada will communicate limited authorization and licence information to Canadian police in response to a request in the context of an investigation under the Controlled Drugs and Substances Act , or the Marihuana Medical Access Regulations .

A6 Declarations and Signature

  1. I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations concerning the safety and effectiveness of marihuana as a drug. I understand the signi ficance of this fact.

  2. I have discussed the potential benefits and risks of using marihuana with the medical practitioner named in Form B1 or B2 (whichever is being filed with this application).

  3. I consent to using marihuana only for the treatment of the symptom stated in the medical declaration.

  4. I am aware that the benefits and risks associated with the use of marihuana are not fully understood and that the use of marihuana may involve risks that have not been identified; and I accept those risks.

  5. If the daily amount stated is more than five grams;

    1. I have discussed the potential risks associated with an elevated daily consumption of dried marihuana with my medical practitioner named in Form B1 or B2 (whichever is being filed with the application), including risks with respect to the effect on my cardiovascular and pulmonary systems and psychomotor performance, risks associated with the long-term use of marihuana, as well as potential drug dependency.

    2. I accept these risks.

  6. I attest that the information on this form is correct and complete.
  • Applicant's Signature
  • Date
  • Print Name

Important:

  1. It is important to understand that all mandatory information requested must be provided to avoid unnecessary delays.
  2. We cannot process the application until ALL appropriate forms are received.
  3. Please retain a photocopy of this form for your files.
    If you have questions regarding this form, please contact Health Canada toll-free at 1-866-337-7705.
Table of Contents
Date Modified: 2011-06-17

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