• 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:
• 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 B1 or B2).

• Mrs.
• Miss.
• Ms.
• Mr.
• Designated person'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:
• Mailing Address (if different from above):
  • Address or P.O.Box:
  • Apartment Number:
  • City:
  • Province:
  • Postal Code:

Please complete and check both boxes:

• Two copies of a current photograph that clearly identifies the designated person have been enclosed.
• The back of one photograph of the designated person has been signed by the applicant (not the designated person) certifying that it is a true likeness of the designated person.

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: A photograph is required every year.

Please choose one of the following three options:

• As the designated person, I plan to produce marihuana at my ordinary place of residence (the address that was provided on Page 1 of this form).

OR

• As the designated person, I plan to produce marihuana at the applicant's ordinary place of residence (the address that was provided by the applicant on Page 1 of Form D).
  If you make either of these two selections, please proceed directly to D5 .
  If not, please check the box on page 3 and provide the requested information.

OR

• As the designated person, I plan to produce marihuana somewhere other than either at my ordinary place of residence or at the ordinary residence of the applicant.
  If you make this selection, please complete the rest of this page.
• Proposed production site:
  • Address:
  • Apartment Number:
  • City:
  • Province:
  • Postal Code:
• If no street address is available, please provide lot and concession number:
  • Lot Number:
  • Concession Number:
• This site is owned by either the applicant or the designated person:
  • Yes
  • No

IMPORTANT: If the marihuana is to be produced at a site that is not the ordinary residence of and not owned by the applicant or the designated person, the owner(s) of the production site must complete Form F: Consent of Property Owner.

The marihuana will be produced (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 the declaration on D8 Part B 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 61(1)).

• 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 the ordinary place of residence of the designated person or the applicant.

I, the applicant, declare and confirm that the information contained in this form is correct and complete.

• Applicant's Signature
• Date
• Print Name

I, the designated person, declare that:

1. Within the ten (10) year period preceding the date of this application, I have not been convicted as an adult of a designated drug offence committed in Canada and that I have attached a document from a Canadian police force in support of this declaration. (Note: Please consult the Applicant Guide for explanation of "designated drug offence.")
2. I declare that, within ten (10) years preceding the date of this application, I have not been convicted, as an adult, of an offence committed outside of Canada that, if committed in Canada, would have constituted a designated drug offence.
3. 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.
4. I declare and confirm that the dried marihuana will be stored indoors.
5. I declare and confirm that the information contained in this form is correct and complete.

• Designated Person's Signature
• Date
• Print Name