Applicant Information

Please select which situation applies to you

Address

Physical address - Primary Physical Residence must be in Canada. If providing a box # you must also include your physical residence.

Mailing address - Address where you receive your usual mail correspondence. If different than above.

Shipping address - Must be physical or mailing address.
Ship To Physical Address
Ship To Mailing Address

Establishment information

Mailing address - Address where you receive your usual mail correspondence. If different than above.

Shipping address - Must be physical or mailing address.
Ship To Physical Address
Ship To Mailing Address

Declaration of the manager of the establishment:

Persons Responsible

Person responsible for the Applicant

Person responsible for the Applicant

Person responsible for the Applicant

Declaration of the Applicant or the Person Responsible For the Applicant

Important, please read and sign below:

• The applicant acknowledges that medical cannabis is not approved for the use as a drug in Canada, that its indications, safety and risks have not been adequately studied and the appropriate dosage is unclear. The applicant acknowledges and agrees that he or she is using any medical cannabis product obtained from AtlantiCann Medical Inc. at his or her own risk, and releases AtlantiCann Medical Inc. from any and all actions, claims, complaints and demands for damages, loss or injury whatsoever arising directly or indirectly as a consequence of the use of medical cannabis obtained from AtlantiCann Medical Inc.
• The applicant is ordinarily a resident in Canada.
• The information in the application and Medical Document or Registration Certificate is correct and complete and has not been altered to the knowledge of the applicant.
• The Medical Document or Registration Certificate is not being used to seek or obtain cannabis products, or cannabis oil from another source.
• The original Medical Document or copy of Registration Certificate is provided in support of this application or has/will be sent separately.
• The applicant will use the cannabis product only for their own medical purposes.
• The applicant gives consent to AtlantiCann Medical Inc. to forward the necessary personal information to our production licensed producer, the applicant’s health care practitioner and service providers for purchasing, shipping, verification and distribution purposes only. Note: this consent isrequired to receive our products.
• The applicant gives consent to his or her health care practitioner to forward the necessary personal information to AtlantiCann Medical Inc. in order to register the applicant and fulfill his or her orders.