aurora cannabis inc. email: …...*to be completed by the individual responsible for the applicant...
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*Mailing Address(If different fromabove)
REGISTRATION APPLICATION
Aurora Cannabis Inc.
P.O. Box 209Cremona, AB. T0M 0R0Phone: 1-‐844-‐928-‐7672
Email: [email protected]
Fax: 403-‐637-‐3121
Applicant Information
Client Name
Date of Birth Gender
Residing Address
Contact Info
Given Name
Please note that the personal information provided on this form must match the information that appears on your Medical Document.Please contact our client care team at 1-‐844-‐928-‐7672 if you require any assistance while completing this application.
Year
Residing Address
Month Day
Surname
Male
Unit Number
City Province Postal Code
Phone(Complete one or more)
Email Fax
(If applicable)
Mailing Address Unit Number
City Province Postal Code
(If applicable)
Female
Is the address above an establishment that is not a private residence?
If yes, please complete sec.on A on the following page:
Yes No
Mailing Address of Residence
Adult Application – QAF-‐021A.02
Please provide the mailing address associated with the residence listed above.
Same as residen*al address above
All fields are mandatory unless specified with an * and relative notes. Clarification to those fields may be provided.
NOTE: This is the address we will ship your product to.
This address must be either your residing address, the mailing address of the residence, or the business address of the Health CarePrac%%oner who completed the Medical Document and has consented to receive marijuana on your behalf (please note: Applicantswithout a residen-al address must have their product shipped to the Health Care Prac--oner who completed their MedicalDocument.)
Same as mailing address
Same as residing address
Health care prac**oner's business address as specified in the Medical Document (please fill out sec*on B on the following page)
Shipping Address
*To be completed by the individual responsible for the applicant (if applicable).
Name
Given Name Surname
Date of Birth Gender
Year Month Day
Male Female
Signature
Please complete this sec-on if your Health Care Prac--oner has agreed to receive medical marihuana on your behalf and has ini-aledthe relevant sec+on on the bo.om of the Medical Document. Product will ship to the business address specified on the MedicalDocument.
Note to Applicants: If at any time your Health Care Practitioner wishes to withdraw their consent to receive medical marihuana onyour behalf, they must send a written notice to that effect to both you (Applicant) and Aurora (Licensed Producer).
Year Month Day
Year Month Day
Signature Date
Date
Signature of Applicant/Responsible Individual
Signature of Responsible Individual
I,Name of Applicant/Responsible Individual
, consent to allow my Health Care Practitioner to recieve medical marihuana on my behalf.
I,Name of Responsible Individual Name of Applicant
, attest that I am responsible for
Section B: Health Care Practitioner Delivery
Individual Responsible for Applicant
Adult Application – QAF-‐021A.02
Contact Info
Phone(Complete one or more)
Email Fax
Type Name
Name of Establishment(example: nursing or care home)
Section A: Non-‐Private Residence
Signature
Year Month Day
Date
Signature of ManagerI hereby cer(fy that I am a manager of the above listed establishment and that we provide food, lodging, or other social services to theApplicant listed above.
*Required if address is non-‐private
*Required if shipping product to Health Care Prac66oner
Acknowledgement of Applicant or Responsible IndividualThe applicant acknowledge that medical marihuana is not approved for use as a drug in Canada and that its risks anddosages have not been determined. The applicant acknowledges that he/she is using medical marihuana at their ownrisk and that Aurora cannabis is not liable for any damages, loss, or injury that results from the use of medical marihuana.
The Applicant acknowledges that some of the information provided in this document may be shared with our serviceproviders for shipping purposes only.
The applicant understands and acknowledges that any Medical Documents sent with this form can not be returned onceregistration is complete.
The applicant ordinarily resides in Canada.
The information in this application and the Medical Document is correct and complete.
The Medical Document is not being used to seek or obtain dried marihuana from another source.
The original of the Medical Document accompanies the application.
The applicant will use dried marihuana only for their own medical purposes.
Signature
Date
Year Month Day
Signature of Applicant
OR
Signature of Responsible Individual (if applicable)
Adult Application – QAF-‐021A.02