• Mrs.
• Miss.
• Ms.
• Mr.
• Applicant 's full name:
  • last
  • first
  • middle
• Date of Birth:
  • day
  • month
  • year
• Telephone: ()
• E-mail:
• If you already hold an Authorization to Possess dried marihuana under these Marihuana Medical Access Regulations, please indicate the number of that Authorization :

IMPORTANT: If you have not been authorized to possess dried marihuana under the Marihuana Medical Access Regulations, you must also submit Form A: Application for Authorization to Possess Marihuana for Medical Purposes and the appropriate medical practitioner form (Form B1or B2).

Please choose one of the following options:

• I plan to produce marihuana at my ordinary place of residence (the address that was provided in Page 1 of Form A: Application for Authorization to Possess Marihuana for Medical Purposes ).
  
  If you check the box above, please proceed directly to C3 .
  If not, please check the box below and provide the requested information.

OR

• I plan to produce marihuana somewhere other than at my ordinary place of residence (the address that was provided on Page 1 of Form A: Application for Authorization to Possess Marihuana for Medical Purposes ).
  
  If you make this selection,please complete the rest of this page.
• Proposed production site:
  • Address:
  • Apartment Number:
  • City:
  • Province:
  • Postal Code:
• I own, or am part owner of, this site:
  • Yes
  • No

IMPORTANT: If you plan to produce marihuana at a site that is not your ordinary place of residence and is not owned by you, you must get the owner(s) of the production site to complete Form F: Consent of Property Owner .

I plan to produce marihuana (please choose only one):

• entirely indoors;

OR

• entirely outdoors;

OR

• indoors in the winter and outdoors in the summer.

IMPORTANT:

1. The Regulations allow you to grow marihuana indoors in the winter and outdoors in the summer. You cannot grow marihuana indoors and outdoors at the same time.
2. Please be sure to read Part C5 of this form with respect to growing marihuana near locations frequented by minors if you plan to grow marihuana outdoors.

IMPORTANT: The Marihuana Medical Access Regulations state that "the holder of an authorization shall maintain measures necessary to ensure the security of marihuana in their possession." (Sec

• Please describe the security measures that will be used at the proposed production site to protect your crop of marihuana against loss or theft:
• Please describe the security measures that will be used to protect your dried marihuana against loss or theft:
• Address where the marihuana will be stored:
  • Address:
  • Apartment Number:
  • City:
  • Province:
  • Postal Code:

IMPORTANT: Please note that if the marihuana is not stored at the production site, it must be stored at your ordinary place of residence.

1. If I've indicated on this application that I plan to produce marihuana outdoors, I declare and confirm that the production site does not share a border or common point of contact with a school, public playground, day-care facility or other public place frequented mainly by persons under 18 years of age.
2. I declare and confirm that the dried marihuana will be stored indoors.
3. I declare and confirm that the information contained in this form is correct and complete.

• Applicant's Signature
• Date
• Print Name