Personal Info
First Name
Last Name
Date of Birth
Your Email
Phone Number
Are you an existing JWC patient?
Are you having your medical document transferred from an existing licensed producer?
Are you a veteran?
Primary Address
Street Address
Unit Number
Postal Code
Is your shipping address different from your primary address?
Are you the Applicant's Caregiver?
Is this a private address?
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.
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