Completing the Production for Own Medical Purposes and Production by a Designated Person Registration Form

Section 1: Application Type

In this section you (as the applicant) will have to select the reason why you are completing the Registration Form.

  • If this is the first time you are applying (e.g. you do not currently hold a Medical Cannabis Registry registration number), please select New and proceed to Section 2 of the Registration Form.
  • If you wish to Renew your registration, please select Renew, and write:
    • The MCR registration number for the registration you wish to renew.
    • Then proceed to section 2.
    • Please note that for a renewal, you will still need to complete the registration form like you did when you first registered.
  • If you are already registered with Health Canada and would like to change something in that registration, please select Amendment. You then fill out the six (6) fields that follow:
    • For the Registration number, you indicate the MCR number of your registration. This will be found on your Registration Certificate.
    • For Description of proposed change, you need to write a short description of what is to be changed (e.g. changing my last name, changing the production site.)
    • For Reason(s) for Proposed Change, you need to write why you are making the change.
    • You then need to write down the date the change will take effect, or took effect.
    • Then, you need to complete Section 2 with your personal information.
    • Once you complete Section 2, complete any section that pertains to the change you want to make. For example, if you are producing for yourself and are changing your production site, you would complete Annex A.
    • Only in case of a name change for a registered person, responsible individual, or a designated person, you will be required to send proof of change along with this registration form. (e.g. Certificate of name change, or photocopy of government issued identification)

Section 2: Applicant's Information

In this section, you are required to provide your personal information. It is mandatory to complete all fields, unless they are marked if applicable.

  • You must write your last name and first name, as well as any middle name that you use.
  • Indicate if you associate as a man or a woman by checking the appropriate box. If you do not associate to any gender, please select X.
  • Your date of birth must be written down as year-month-day.
  • You need to provide a phone number and indicate if it is a home phone or a cellular phone. You can also provide a fax number and email address.
  • Select the language you wish Health Canada to use when communicating with you. Please note that some of Health Canada's correspondence may be provided in both official languages, regardless of the language you choose on the Registration Form.
  • After you write the address of your ordinary place of residence, you must select what best describes the building for the address you provided.
    • For example, if you live in an apartment, you would select Private residence - Apartment. If, however, you live in a long term care facility, you would select Not a private residence - Hospice.
  • If your mailing address is different than the address of your ordinary place of residence, you must provide your mailing address.
  • When you submit a registration form for a new request, a renewal or an amendment that affects your daily amount as specified by a health care practitioner, you must include a medical document with your registration form. Check the box to confirm that you have included your medical document.

Please note that unless a field is marked if applicable, the information must be provided. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

Section 3: Responsible Individual (this section is optional)

This section is optional. It is to be filled out only if an individual is responsible for the applicant. If this is the case, the Responsible Individual should provide their contact information in section 3A, and sign and date the registration form. This would apply when a parent is caring for a child, or an adult is caring for another adult who is incapacitated.

3A. Responsible Individual's Information

In this section, the Responsible Individual is required to provide their personal information. It is mandatory to complete all fields, unless they are marked if applicable.

  • They must write their last name first and first name, as well as any middle name they use.
  • Indicate if they associate as a man or a woman by checking the appropriate box. If they do not associate to any gender, they can select X.
  • Their date of birth must be written down as year-month-day.
  • They need to provide a phone number and indicate if it is a home phone or a cellular phone. They can also provide a fax number and email address.
  • The responsible individual must select the language they wish Health Canada to use when communicating with them. It should be noted that some of Health Canada's correspondence may be provided both official languages, regardless of the language chosen.
  • They need to provide their mailing address.
  • If their mailing address is different than the address of their ordinary place of residence, the Responsible Individual must provide their mailing address.

3B. Statement - Responsible Individual

The Responsible Individual must sign and date to confirm that they have read the declaration.

Section 4: Proposed Type of Production of Cannabis

In this section you have to indicate how you propose to produce cannabis by selecting one of the options below.

Tick the box for the option you select; you can only select one.

  • Personal-use Production - Selects this option if you plan to produce your own cannabis. You will then need to complete Annex A.
  • Production by Designated Person - Select this option if you plan to have a Designated Person produce cannabis for you. You will then need to complete Annex B.

Please note that the portion about the proposed type of production is mandatory. If you do not select one of the options, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

It is possible to obtain starting material such as seeds or seedlings from a Licensed Producer. If you need to obtain starting material, please tick yes. Please note that you will only be able to obtain starting material from a Licensed Producer if, and when, you are provided with a Registration Certificate from Health Canada.

It is also possible to obtain an interim supply from a Licensed Producer while you wait for your harvest. If you need to obtain an interim supply, please tick yes.

Please note that you will only be able to obtain interim supply from a Licensed Producer if, and when, you are provided with a Registration Certificate from Health Canada.

Section 5: Authority to communicate with police

This section is included for your information. Please read carefully, as when you sign the registration form, you recognize that you were made aware of this information.

Section 6: Applicant's Declaration and Signature - Possession

Please read all the declaration information carefully and thoroughly. Please tick the check box - this will provide your attestation.

Next, print your name, sign, and date the form.

Please note that this section is mandatory. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

 

Annex A - Registration Form Annex for Personal-Use Production

This Annex is to be completed if you have indicated that you plan to produce your own cannabis under Section 4 of the Access to Cannabis for Medical Purposes Regulations Registration Form.

If you have indicated that you plan to have a designated person produce the cannabis for you, you must complete Annex B; you can disregard Annex A.

A1: Production Site

In this section, please select one of the options provided. You can only select one.

  • Choose the first option if you will produce cannabis at your ordinary place of residence (the address you provided in section 2 of the registration form). You can then skip section A2 and proceed to section A3.
  • Choose the second option two if you plan to produce cannabis somewhere other than your place of residence. If you selected this option, you will need to write the address of the site in the space provided on the form.

You then need to indicate if you are the owner, or part owner, of the site where you plan to produce cannabis.

  • If the answer is yes, check Yes and skip section A2. You can proceed to section A3.
  • If the answer is no, check No and complete section A2. The site owner will need to review, date and sign section A2.

Please note that unless a field is marked if applicable, the information must be provided. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

A2. Site Owner's Consent

You can complete this section with the information of the site owner, but the site owner will need to sign and date this section.

The personal information is to be provided for the site owner. In addition to their name, this includes their address and phone number.

The site owner will need to read the statement, print your name (as the person they are giving consent to) on the line and then sign and date the section.

If the property is co-owned, the co-owner will also need to provide their information and to read the statement, print your name (as the person they are giving consent to) on the line and then sign and date the section.

This section is optional and does not have to be completed if there is no need. However, if it is completed, please note that unless a field is marked if applicable, the information must be provided. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

A3: Production Area

In this section, please select how you plan to produce the marihuana plants. You can only choose one option.

  • You can produce your marihuana plants entirely outdoors
  • You can produce your marihuana plants entirely indoors
  • You can produce your marihuana plants indoor in winter and outdoors in summer

Please note that the portion about the production area is mandatory. If you do not select one of the options, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

A4: Storage Site

In this section, please select where you will store your cannabis. You can store your cannabis either at your ordinary place of residence or at the production site.

Please note that the portion about the storage site is mandatory. If you do not select one of the options, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

A5: Applicant's Declaration and Signature - Personal Production

Please read all the declaration information carefully and thoroughly. As you read each section, please tick the check box. Once you have read the declaration, sign and date the form.

Please note that this section is mandatory. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

 

Annex B - Registration Form Annex for Production by a Designated Person

This Annex is to be completed if you have indicated that you plan to have a Designated Person produce cannabis for you under Section 4 of the Access to Cannabis for Medical Purposes Regulations Registration Form.

If you have indicated that you plan to produce your own marihuana, you must complete Annex A; you can disregard Annex B.

B1: Designated Person's Information

In this section, the Designated Person is required to provide their personal information. It is mandatory to complete all fields, unless they are marked if applicable. Ideally, your designated person should complete this Annex given that they must provide personal information, read the declaration and sign and date the form.

The Designated Person must:

  • write their last name and first name, as well as any middle name that they use.
  • indicate if they associate as a man or a woman by checking the appropriate box. If they do not associate to any gender, they can select X.
  • write their date of birth (year-month-day).
  • provide a phone number and indicate if it is a home phone or a cellular phone. They can also provide a fax number and email address.
  • select the language they wish Health Canada to use when communicating with them. Please note that some of Health Canada's correspondence may be provided both official languages, regardless of the option chosen.
  • provide the address of their ordinary place of residence.
  • indicate if their ordinary place of residence is a private residence (e.g. a house, an apartment, a condo.) If it is not, they must write the name of the establishment, and the type.
  • indicate if their mailing address is different than the address of their ordinary place of residence. If different, they must provide their mailing address.

Important: When you submit a registration form for a new request, a renewal or an amendment that affects your daily amount as specified by a health care practitioner, you must include a medical document with your registration form. Check the box to confirm that you have included your medical document.

Please note that unless a field is marked if applicable, the information must be provided. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

B2. Police Document

A Designated Person must provide the original version of a document issued by a Canadian police force establishing that within the 10 years preceding the application, they have not:

  • been convicted, as an adult, of a designated drug offense, as defined in section 2 of the Narcotic Control Regulations.
  • been convicted of a designated drug offence as a young person in ordinary court, as those terms were defined in subsection 2(1) of the Young Offenders Act, chapter Y-1 of the Revised Statutes of Canada, 1985, immediately before that Act was repealed.
  • received, as a young person, an adult sentence, as those terms are defined in subsection 2(1) of the Youth Criminal Justice Act, in respect of an offence referred to in the first point above.

The check box found under section B2 of the registration form should be checked to confirm that the document is included with the registration form. If this document is not included, the registration form will be deemed incomplete and returned to the applicant.

B3. Production Site

In this section, please select one of the options provided. You can only select one.

  • Choose the first option if the Designated Person will produce cannabis at their ordinary place of residence (the address provided in section B1 of this Annex). You can then skip section B4 and proceed to section B5.
  • Choose the second option if the Designated Person will produce cannabis at the applicant's ordinary place of residence (the address you provided in section 2 of the registration form). You can then skip section B4 and proceed to section B5.
  • Choose the third option if the Designated Person plans to produce cannabis somewhere other than their place of residence or the place of residence of the applicant. If this option is selected, write the address of the site in the space provided on the form.

Indicate if the Designated Person is the owner, or part owner, of the site where they plan to produce cannabis.

  • If the answer is yes, check Yes and skip section A2. You can proceed to section A3.
  • If the answer is no, check No and complete section A2. The site owner will need to review, date and sign section A2.

Please note that unless a field is marked if applicable, the information must be provided. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

B4: Production Site Owner's Consent

You can complete this section with the information of the site owner, but the site owner will need to sign and date this section.

The site owner's personal information is to be provided. This includes their address and phone number.

The site owner will need to read the statement, print your name (as the person they are giving consent to) on the line and then sign and date the section.

If the property is co-owned, the co-owner will also need to provide their information and to read the statement, print your name (as the person they are giving consent to) on the line and then sign and date the section.

This section is optional and does not have to be completed if there is no need. However, if it is completed, please note that unless a field is marked if applicable, the information must be provided. If the information is not provided, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

B5: Production Area

In this section, please select how the designated person plans to produce the marihuana plants. You can only choose one option.

  • Marijuana plants can be produced entirely outdoors
  • Marijuana plants can be produced entirely indoors
  • Marijuana plants can be produced indoors in winter and outdoors in summer

Please note that the section regarding the production area is mandatory. If you do not select one of the options, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

B6: Storage Site

In this section, please select where the Designated Person will store cannabis. The Designated Person can store either at their ordinary place of residence or at the production site.

Then, please provide the address of that new location.

Please note that the portion about the storage site is mandatory. If you do not select one of the options, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

B7: Designated Person's Declaration and Signature

The Designated Person must read all the declaration information carefully and thoroughly. As they read each section, they need to tick the check box. Once they have read the declaration, the Designated Person must sign and date the form.

Please note that this section is mandatory. If you do not select one of the options, the registration form will be deemed incomplete. It will not be processed and will be returned to you.

 

Submitting Your Registration Form to Health Canada

Once your registration form is completed and signed, you can submit it to Health Canada by mailing it to the following address:

Health Canada
Registration Process
Address Locator: 0302B
Ottawa, ON K1A 0K9

You must ensure that all required supporting documents are included with your registration form. This includes your medical document and a police document for your Designated Person (if you have a Designated Person).

Your medical document cannot be submitted to Health Canada by your health care practitioner. You must include your medical document with this registration form.

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