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Membership Form

YOU WILL HAVE TO SIGN THIS FORM AND HAVE A COPY OF YOUR RECOMMENDATION FOR OUR RECORDS. GIVE IT TO THE DRIVER WHEN THE DRIVER ARRIVES AT YOUR LOCATION. HE WILL ALSO NEED TO VERIFY YOUR ID AND ORIGINAL RECOMMENDATION. BY SUBMITTING THE FORM YOU ALSO AGREE TO FOLLOW SENATE BILL 420, PROPOSITION 215 AND ANY OTHER STATE REGULATIONS THAT ARE APPLICABLE. BY SUBMITTING THIS APPLICATION YOU ARE AGREEING TO OUR MEMBERSHIP RULES AND REGULATIONS.

First Name: *
Last Name: *
Telephone: *
Email: *
Address: *
City: *
State: *
Zip Code: *
Ca DL # or Ca ID #: *
CA DL or CA ID Exp Date: *
Date of birth: *
Doctor on Recomendation: *
Recomendation Issue Date: *
Recomendation Expiration: *
Recomedation or Patient # if Applicable: *
Verification phone # or website: *
Medical Marijuana Name:
Quantity:
Medical Marijuana Name:
Quantity:
I agree to the rules: Type "yes" or "no": *
Anything Else or Notes:
How did you hear about us?: *
By clicking the submit button you are becoming a member of California Collective Caregivers Group and adhering to SB 420, prop 215 and all other state regulations that apply.

We specialize in: Medical Marijuana delivery within Anaheim, Yorba Linda, Cost Mesa, Brea, La Habra, Placentia, Anaheim Hills and more. Once you apply it is as easy as a phone call to get your Medical Cannabis. CaliCCG or California Collective Care Givers is not a Medical Marijuana Dispensary. There is no facility for you to visit, only a FREE delivery service. California Collective Care Givers make life easy! Apply Now!