Tri-Valley Coop

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Applicant Information

First Name :	*
Last Name :	*
Address 1 :	*
Address 2 :
City :	*
State :	*
Zip Code :	*
Contact Phone :	*
Email :	*
New Password [4 characters minimum] :	*
New Password Confirmation :	*
Driver License Number :	*
MMJ ID :	*
MMJ Expiration Date :	*
Photo ID [or fax to 925-320-7250] :
Physician Letter [or fax to 925-320-7250] :

Physician Information

Doctor's First Name :
Doctor's Last Name :	*
Office Address 1 :	*
Office Address 2 :
Office City :	*
Office State :	*
Office Zip Code :	*
Office Phone :	*
Doctor's License Number :

By Clicking the Register button bellow, I certify that:

1. The information I provided above is correct.

2. I will abide by all laws of the State of California and adhere to the medical marijuana guidelines established by Attorney General Brown in August 2008. Proposition 215 and all other municipal and California State laws, guidelines and ordinances pertaining to the use of medical marijuana.

3. I will never divert any medical marijuana to non-medical users.

4. I will always use any marijuana obtained from my collective in accord with California law.

5. I will never compromise the collective by possession of any illicit drugs, weapons, etc.

6. If I order cannabis-containing medicine, I will take personal delivery, or arrange for my caregiver to do so, to ensure that there is no diversion to a non-member.

SIGNATURE: This Agreement is executed electronically by completion of the online application, and by submission of this form. Completion of the online form by the Member and performance of the services shall have the same effect as live signatures.

I agree with the terms and conditions *