Scribd
Upload
113 views1 page

Application-RIC Change or Reissue

This document is a form for a Maine medical marijuana patient to change or reissue their registry identification card. It requests information such as the patient's name, date of birth, address, and what changes are being made that may require a $10 reissuance fee such as a change in legal name or if the card was lost or stolen.

Uploaded by

sellmarc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
113 views1 page

Application-RIC Change or Reissue

This document is a form for a Maine medical marijuana patient to change or reissue their registry identification card. It requests information such as the patient's name, date of birth, address, and what changes are being made that may require a $10 reissuance fee such as a change in legal name or if the card was lost or stolen.

Uploaded by

sellmarc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

MAINE MEDICAL USE OF MARIJUANA PROGRAM

REGISTRY IDENTIFICATION CARD CHANGE or REISSUE FORM


SECTION 1: CARDHOLDER INFORMATION

Legal Name (Please print):


Michael J. Marcous Registry Identification Card Number: RIC
18358
01/12/1965
Date of Birth: Telephone Number: 2077512348
Mailing Address: 3 Leavitt Ave

City: Lewiston State: ME Zip: 04240


SECTION 2: REPLACEMENT/CHANGE INFORMATION
Card was lost, stolen or damaged ($10.00 Reissuance fee)

Change of information.
The following changes require a replacement card to be printed, and therefore a $10.00 reissuance fee is due for any of the following changes:
Legal Name*:
*Please provide proof of legal name change, such as a marriage certificate, probate court order, or similar legal document.
The following changes do NOT require a replacement card to be printed, therefore there is NO fee due for any of the following changes:
Mailing Address:

Residential Street Address:

Telephone Number:

Email Address:

SECTION 3: FEES
Please enclose required fee of $10.00 for card replacement, if required.

The Office of Cannabis Policy will accept application fees by cashier’s check or money order made payable to the Treasurer, State of
Maine in person or at our mailing address: Office of Cannabis Policy, 162 State House Station, Augusta, Maine 04333-0162.

We are unable to accept personal checks and cash. All fees are non-refundable.

Total bank check/money order enclosed: $___________$51


Signature – This application cannot be accepted without a signature.
I understand that if I have given incorrect information, my application may be denied. I have read and understand the questions above.
Applicant's Signature Date
03/27/2024
Submit completed application and applicable fees to the following address:

Office of Cannabis Policy Tel: (207) 287-9330 or 287-3282; Fax: (207) 287-2671; TTY users: Dial 711 (Maine relay)
162 State House Station E-mail [email protected]
Augusta, ME 04333-0162 Website: www.maine.gov/dafs/ocp
OCP_RIC_CRF
Rev. 05/2022

You might also like