Application for Authorization to Possess Dried Marihuana - Form E1

Form E1 - Application to Obtain Dried Marihuana

This form is to be completed by applicants who wish to obtain dried marihuana only from Health Canada who either:

• hold or have applied for an Authorization to Possess marihuana under the Marihuana Medical Access Regulations;

OR

• hold an Exemption for marihuana for medical purposes under Section 56 of the Controlled Drugs and Substances Act.

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

Note:If purchasing both dried marihuana and marihuana seeds,the dried marihuana will be shipped for a period of up to four months.

E1-1 Applicant 's Information

E1-2 Cost

Dried marihuana will be provided at a cost of $5 for each gram.The quantity provided will be calculated based on your approved daily amounts. If you are unsure of the amount you can order, please call Health Canada toll-free at 1-866-337-7705 for assistance.

Examples of monthly costs:

• 1 gram per day (30 grams) = $150 per month*
• 2 grams per day (60 grams) = $300 per month*
• 3 grams per day (90 grams) = $450 per month*
• 4 grams per day (120 grams) = $600 per month*
• 5 grams per day (150 grams) = $750 per month*

*(plus applicable taxes)

E1-3 Delivery Instructions

IMPORTANT:

1. The quantity provided will be calculated based on the maximum amount of dried marihuana you are allowed, by authorization, to possess. If you are unsure of this amount, please call Health Canada toll-free at 1-866-337-7705 for assistance.
2. The dried marihuana must be delivered either directly to you or to you through your medical practitioner.
   If it is to be sent to you through your medical practitioner, please check with your medical practitioner in advance to ensure that it will be accepted on your behalf.

Note: Before moving on to Section E1-4, please ensure that:

1. If the marihuana is being delivered to your medical practitioner, that you have checked, in advance, to be sure that your medical practitioner will accept delivery of it for you.
2. If the marihuana is being delivered to your medical practitioner, that you have provided the delivery address of your medical practitioner.

E1-4 Notice to Applicants, Declaration and Signature

Please read carefully before using this product.

It is important for you to be aware of the following risks and recommendations about the product:

• Health Canada has not approved this marihuana product, or marihuana generally, as a drug under the Food and Drugs Act.
• The provision of marihuana for medical purposes does not constitute an opinion from Health Canada on the safety, effectiveness or quality of marihuana within the meaning given to those words under the Food and Drugs Act and the Food and Drug Regulations.
• The provision of marihuana does not constitute an opinion from Health Canada as to the justification for using marihuana for medical purposes, in general.
• The use of marihuana carries with it a number of potential health risks, including impaired immune system, interaction with other drugs, dysphoria, depleted energy, impaired short term memory, drug dependence and lung damage (particularly if consumed in the smoked form). If marihuana is to be used for medical purposes, it is recommended that it not be smoked. If you do use the product in smoked form, you accept the additional smoking-related risks.
• You should discuss with your medical practitioner the risks that may be associated with the use of this product, and marihuana generally.
• You should obtain directions for use of this product from your medical practitioner.
• Health Canada strongly recommends regular follow-up visits with your medical practitioner to verify that the benefits associated with the use of marihuana continue to outweigh the risks.
• It is possible that not all potential health risks associated with marihuana use, nor the extent of those risks, have been identified. This product therefore is being provided with the understanding that you acknowledge these facts, and that you voluntarily accept and assume the risks and dangers associated with the use of this product.
• The use of marihuana may have an effect on motor kills. Consequently, if you are consuming marihuana for medical purposes, you are advised not to operate a motor vehicle, handle machinery, or perform other risky activities while under the effects of marihuana. Health Canada recommends seeking the advice of your medical practitioner on this matter. Be advised that the use of marihuana while involved in such activities may constitute a number of offences under the Criminal Code, including dangerous operation of a motor vehicle, operating a motor vehicle while impaired, criminal negligence, and others.
• Health Canada strongly recommends that if you are pregnant, planning to get pregnant, or nursing, you should not consume marihuana.
• Given the nature of marihuana and the fact that the provision of marihuana is for your personal treatment needs, Health Canada recommends not consuming this controlled substance in a public place. Please take note that persons in charge of public or private establishments (e.g., bars and restaurants) can request that you not smoke marihuana on their premises, even if you have authority to possess marihuana for medical purposes.There may also be municipal bylaws that prevent smoking. In addition, others should not be exposed to second-hand marihuana smoke.

1. I have read Section E1-4 of this document titled "Notice to Applicants, Declaration and Signature" and acknowledge that the benefits and risks associated with the use of the product are not fully understood. I understand that the use of the product may involve risks to health that are not known. Further, I understand that Health Canada is not giving any assurances, warranties or approvals with regard to the dried marihuana being provided.
2. I also understand that it is incumbent upon me to ensure that I do not, at any time, have more dried marihuana in my possession than I have been authorized to possess by Health Canada.
3. I attest that the information on this form is correct and complete.

IMPORTANT:

1. Please ensure that you have read the Notice to applicants, Declaration and Signature and have signed the declaration.
2. It is important to understand that all mandatory information requested must be provided to avoid unnecessary delays.
3. We cannot process the application until ALL appropriate forms are received.
4. 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.