Application For Membership

Wed, 03/24/2010 - 22:31 |

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Membership has it privileges. We do a prescreening of prospective patients for the collective online. You can fill out the new collective member form. Then after we confirm your doctors recommendation, we will inform you that you have been approved for membership at the collective.

Name of Person Seeking Membership: *

Your Phone Number:

We need your phone number to inform you that you have been approved to membership of the collective.

Your email:

Name Of Your Doctor: *

Doctors Phone Number: *

We need a phone number or website where we can verify your recommendation.

Website :

Many doctors these days have a website where patients can be verified. If you point us to that website we can verify you sooner. This can also be the state card verification, or OCBC verification or what ever method on line is available for us to confirm your valid recommendation.

Patient Verification Data:

Depending on the site that is used to verify you this could be a number or a combination of a letters and numbers in conjunction with a drivers license or name.

Other Data Needed To Verify You:

This field area is for websites that require a name and drivers license or some other data besides a name.

Expiration Date: *

Date your recommendation expires.

CDL or Statate ID Number: *

We need your California Drivers License Number or State ID number so that when you come into the dispensary we can verify who you are with your state issued I.D.

Copy of your recommendation.: *

We need a scanned copy of your recommendation for our records.

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Application For Membership

Membership has it privileges. We do a prescreening of prospective patients for the collective online. You can fill out the new collective member form. Then after we confirm your doctors recommendation, we will inform you that you have been approved for membership at the collective.