- I hereby certify that I or the institution by or with which I am affiliated or employed is providing services to the Applicant.
- I hereby consent to receive cannabis on behalf of the Applicant listed above.
- I hereby certify that I am responsible for the Applicant named above.
Note: If at any time you wish to withdraw consent to receive cannabis on behalf of the Applicant, you must provide written notice to that effect to both the Applicant and the Licensed Producer.
Please make sure all form inputs are correctly filled in.
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