as evidence that I live in a state that authorizes marijuana for medical
purposes and have a debilitating condition authorized under Maine law.
I have also provided you with a copy of my Maine provider certification
and a copy of my photographic identification card or driver’s license
from my home jurisdiction. As a visiting qualifying patient, I agree to
abide by all terms and conditions of the Maine Medical Use of Marijuana
You are hereby authorized to share this caregiver designation form and
any copies of documents that I am required to provide to a member of the
law enforcement community in order to verify the services you are providing
to me are authorized under Maine law.
I have the right to terminate this agreement at any time. This MMMP designation
form and designation card is my property, and any authorized activity conveyed
to you through this designation form terminates upon my notice. You must
either dispose of the excess marijuana in your possession on my behalf,
or replace me with another qualified patient. You will have 10 days from
the date of notice to return this form to me.
In the event I terminate this agreement and you do not return this designation
form to me, I authorize the Maine Department of Health and Human Services
to demand the return of this designation form and card or take other action
to enforce the Rules Governing the Maine Medical Use of Marijuana Program,
which includes terminating the caregiver number that they assigned to you
and that you have listed on this designation form.