Register With JWC
Required fields are marked with a *
Personal Info
First Name
Last Name
Date of Birth
Gender
Your Email
Phone Number
Fax Number
Are you an existing JWC patient who is renewing?
Yes No
Are you a veteran?
Yes No
Primary Address
Street Address
City
Postal Code
Province
Is your shipping address different from your primary address?
Yes No
Is this a private address?
Yes No
Applicant Declaration
The following declaration should be signed either by the Applicant or the person responsible for the Applicant:
  • I hereby certify that the Applicant named herein is normally a resident in Canada.
  • I and/or the Applicant have read the “General Terms and Conditions” as published on the web site included in the “James Wagner Cultivation Network” (as therein defined) which I agree to incorporate into this document by reference, and to which I acknowledge that I am bound.
  • I further certify that information given in this application and in any appended documents (i.e. proof of legal name change) is both correct and complete.
Name
Date