http://www.maine.gov/sos/images/sealcol2.jpgSTATE OF MAINE

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Maine Center for Disease Control and Prevention

Medical Use of Marijuana Program

Employee Application

 

 

SECTION 2: Fees

   Employee Applicant Fee: $20

   Criminal Background Check: $31.00 (Mandatory Annually)

All FEES ARE NON-REFUNDABLE (SECTION 7.1 MMMP RULES)

 

$                           

 

$                            

Make bank check or money order payable to “Treasurer, State of Maine”.

We are unable to accept personal checks, cash and credit cards.

Total Bank Check/Money Order enclosed:

 

 

$                      

 

 

 

Submit completed application and applicable fees to the following address:

Department of Health and Human Services Maine Center for Disease Control and Prevention Maine Medical Use of Marijuana Program

286 Water Street  11 State House Station Augusta, ME 04333-0011

Tel: (207) 287-8016                            Fax: (207) 287-2671                                            TTY users: Dial 711 (Maine relay)

 

Email: DHHS.MMMP@maine.gov

Website:    www.mainepublichealth.gov/mmm

 

 

 

 

 


 

SECTION 3: Employer Information

Legal Name of Employer:

Mailing Address:

City:

State:

Zip:

County:

Telephone Number: (       )

Caregiver Employer DOB:

 

 

SECTION 5: Declaration

 

·         I UNDERSTAND and acknowledge my duties, rights and responsibilities as a card holder under the laws and regulations governing the Maine Medical Use of Marijuana Program (MMMP).

·         I AGREE that in the event that law enforcement questions my status as an employee cardholder, I must provide my registry identification card and current Maine State issued photo ID.

·         I UNDERSTAND that if I do not comply with these requirements, the Department of Health and Human Services may revoke the registry identification card.

·         I DECLARE under penalty of perjury that the information provided on this form is true and correct.

·         I UNDERSTAND that I must submit a new application each time I apply for a card and/or renew a card.

·         I CERTIFY that I will not sell, furnish, or give marijuana to a person who is not allowed to possess marijuana for medical purposes.

·         I UNDERSTAND that as a registered employee, I am not authorized to conduct myself as a caregiver with all benefits and responsibilities associated with such designation.

·         I UNDERSTAND that if my employer terminates my employment, I am no longer protected under the Act and I must submit my registry identification card to the MMMP.

·         I UNDERSTAND that all fees are nonrefundable (Section 7.1 MMMP Rules).

 

 

 

Print name of Employee                                                  Signature of Employee                                              Date

 

 

 

 

Print name of Employer                                                   Signature of Employer                                               Date