Dear Applicant,
Per Alaska Statute 17.37.010 regarding the medical uses of marijuana, the enclosed "Application for Registry Identification Card for Medical Use of Marijuana" and "Physician Statement" must be completed by the applicant. Further, if a primary or primary alternate caregiver is specified, the form "Caregiver Application for Medical Use of Marijuana Applicant" must also be completed.
A nonrefundable fee (7 AAC 34.070(b)) of $25.00 ($20.00 for a renewal) and a legible photocopy of the Alaska State Driver’s License or Identification Card of the patient and all caregivers must be submitted with the application. Renewal applications submitted after a registry identification card has expired will be considered a new application and the applicant will be required to pay the fee for first-time applicants.
Prior to mailing your application, review it to be sure that all required information has been completed. If your application is not complete, it will be denied and you will not be allowed to reapply for a period of six months. Please make your check or money order payable to the Bureau of Vital Statistics and mail it along with the application to the following address:
Alaska Bureau of Vital Statistics Marijuana Registry P.O. Box 110699 Juneau, AK 99811-0699
You may wish to use "Return Receipt Service" for mailing to be sure that your application and fees are received by the Bureau.
Lastly, enclosed is page for your reference that provides the statutory requirements regarding the application for a marijuana registry card. If you have any questions or concerns, please contact the marijuana registry section of the Bureau of Vital Statistics at (907) 465-5423.
[FONT=Arial,Arial][FONT=Arial,Arial]PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY. IF YOUR APPLICATION IS NOT COMPLETE IT MAY BE DENIED.
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A patient applying for a medical marijuana registry identification card must provide to the department:
(1) The [FONT=Arial,Arial][FONT=Arial,Arial]original completed copy [/FONT][/FONT]
of the attached application form (we cannot accept photocopies of your completed application) that includes the following:
 The applicant's name, mailing address, physical address (if different from the mailing address or the mailing address is a P.O. Box), and date of birth;
 A photocopy of the applicant’s Alaska driver’s license or Alaska identification card;
 The applicant's signature;
 The name, address, and telephone number of the patient's physician;
 The name and address of the patient's primary and secondary caregiver, if one is designated at the time of application;
 A photocopy of the primary or secondary caregivers (if applicable) Alaska driver’s license or Alaska identification card;
 The primary and secondary caregivers signature;
(2) If the applicant is a minor, an original statement in writing (we cannot accept photocopies) by the minor's parent or legal guardian residing in Alaska, stating that the parent or guardian:
 Consents to serve as the minor's primary caregiver; and
 Gives the parent or guardian's permission for the minor to engage in the medical use of marijuana;
(3) [FONT=Arial,Arial][FONT=Arial,Arial]The original, signed form of the physician’s statement [/FONT][/FONT]
(we cannot accept photocopies of the physician’s statement) stating that the patient has been diagnosed with a qualifying debilitating medical condition and the conclusion of the patient's physician that the patient might benefit from the medical use of marijuana or a certified copy of that documentation; and
(4) The application fee of $25 for the original request or $20 fee if it is for a timely renewal (your current card has not expired).
[FONT=Arial,Arial][FONT=Arial,Arial]Application for Registry Identification Card For Medical Use of Marijuana
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[FONT=Wingdings,Wingdings].
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[/FONT][FONT=Arial,Arial][FONT=Arial,Arial]Initial Application [/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]. [/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial]Renewal [/FONT][/FONT](Card No. )
[FONT=Arial,Arial][FONT=Arial,Arial]Applicant Name:
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[/FONT]First Middle Last [FONT=Arial,Arial][FONT=Arial,Arial]Mailing Address: Physical Address: City, State Zip: Phone: [/FONT][/FONT]City State Zip [FONT=Arial,Arial][FONT=Arial,Arial]Date of Birth: / / Alaska Drivers License/ID Number: [/FONT][/FONT]Month Day Year
[FONT=Arial,Arial][FONT=Arial,Arial]If the Applicant is a Minor (Under the Age of 1
, Please Fill Out This Section
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[/FONT]I, , state that I am the parent or guardian of (Name of parent or guardian) (Minor applicant’s name) and that the minor’s physician has explained the possible risks and benefits of medical use of marijuana to me and that I consent to serve as the primary caregiver for the patient and to control the acquisition, possession, dosage, and frequency of use of marijuana by the minor. [FONT=Arial,Arial][FONT=Arial,Arial]Parent or Guardian Signature: Date: Note: The parent or guardian must also register as the applicant’s primary caregiver (page 2). [/FONT][/FONT]
[FONT=Arial,Arial][FONT=Arial,Arial]Physician Information Name: Phone:
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[/FONT]First Middle Last [FONT=Arial,Arial][FONT=Arial,Arial]Mailing Address: Physical Address: [/FONT][/FONT](If different from mailing address) [FONT=Arial,Arial][FONT=Arial,Arial]City, State Zip: [/FONT][/FONT]City State Zip
[FONT=Arial,Arial][FONT=Arial,Arial]Applicant's Signature: Date: Witness Name: Witness Signature: Date:
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[/FONT][FONT=Arial,Arial][FONT=Arial,Arial](Note: The witness must be present when the applicant signs and the witness should sign immediately after the applicant.)
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]. [/FONT][/FONT]Application fee enclosed ($25 initial application; $20 renewal application). [FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]. [/FONT][/FONT]Attach a statement from the patient’s physician, using either the physician’s statement form (page 4) or a letter addressing the conditions mentioned in the physician’s statement form, signed by the patient's physician.
