Membership Agreement

MEMBERSHIP APPLICATION AND AGREEMENT
MARIJUANA DELIVERY SERVICE (MDS)

A California Nonprofit Mutual Benefit Corporation

As a qualified patient protected by California Law, Health & Safety Code 11362.5 and 11362.7, et seq., and in conjunction with California Health & Safety Code 11362.775, you are required to read and agree to the following to become a member of Marijuana Delivery Service. Please read the following statements and initial that you have read each where provided. Please sign the end of this form confirming that you have read each statement and understand them. Marijuana Delivery Service (“Collective”), a NON-PROFIT Consumer Cooperative Corporation facilitates the association of qualified medical patients for the purpose of collectively cultivating medical cannabis for its members, pursuant to Health & Safety Code sections 11362.765 and 11362.775. The Collective is dedicated to providing the highest quality cannabis products and services pursuant to the Compassionate Use Act and Medical Marijuana Program Act – Health & Safety Code 11362.5, et seq. This agreement contains member requirements and guidelines to ensure compliance with the Compassionate Use Act, Medical Marijuana Program Act and the Attorney General Guidelines for the security and non-diversion of cannabis grown for medical use, to protect the safety and health of our members and to continue our goal of operating a community-based, patient-run alternative healing organization.

1. I am a qualified patient entitled to the protection of California Health & Safety Code section 11362.5, et seq., because my physician has recommended and approved my use of cannabis for medical purposes.

PATIENT/MEMBER INITIALS ______

2. I have the right to obtain and use cannabis for medical purposes where that medical use has been deemed appropriate and has been recommended/approved by a California physician who has determined that I suffer from a serious medical condition for which medical cannabis provides relief and has provided a written recommendation that verifies this fact. As a condition to membership to the Collective, I have provided a copy of such recommendation to the Collective, as well as a copy of my current California driver’s license or other state issued identification. I understand that the Collective will keep a copy of these documents on file and will independently verify with my physician my medical recommendation which forms the basis for my right to be considered a qualified patient under California Law.

PATIENT/MEMBER INITIALS ______

3. In order to acquire the medical cannabis per my physician recommendation, and in accordance with Health & Safety Code 11362.5, et seq., I hereby seek membership in the Collective and understand that in order to be a member of the Collective, and to maintain my membership in the Collective, I must agree to, and follow all terms and conditions set forth in this agreement.

PATIENT/MEMBER INITIALS ______

4. I agree to provide the Collective with my current medical recommendation. I understand that I will have to provide my current medical recommendation every time I obtain my medical cannabis. I understand that any member whos recommendation is expired shall be excluded from membership until such time that their qualified status pursuant to the Compassionate Use Act can be established and verified.
PATIENT/MEMBER INITIALS ______
5. I understand that as a member of the Collective, I agree to assist, if necessary, in any aspect of the cultivation process in which I am capable of including, but not limited to, cutting clones, trimming, and/or reimbursing actual costs incurred. I also understand that I may be called upon to contribute finances, labor and/or resources to the Collective. Such contributions are necessary to cultivate my medical cannabis as well as conduct the day-to-day operations of the Collective for the benefit of its members.

PATIENT/MEMBER INITIALS ______

6. I have been informed and understand that there will be a bi-annual meeting of all members of the Collective for the purposes of voting as to the operation of the Collective and that I will be advised of the bi-annual meeting by U.S. mail, email and/or published notice at the Collective not less than ten (10) nor more than ninety (90) days before the date of the meeting. I understand that my attendance is very important in order to help make decisions necessary to day-to-day operations of the Collective for the benefit of all members.

PATIENT/MEMBER INITIALS ______

7. I have been informed and understand that the Collective will make available to me at the time of the bi-annual meeting or upon reasonable request records verifying the reimbursement necessary to compensate patient-members’ out of pocket expenses, time spent and any and all operational expenses incurred in the course of cultivating and otherwise making available medical cannabis on behalf of the Collective.

PATIENT/MEMBER INITIALS ______

8. I agree to assign agency rights to the Collective for the limited purposes of obtaining legally cultivated medical cannabis and for the purposes of growing medication for my benefit. I understand that the Collective is required to possess, transport and cultivate medical cannabis on my and other members’ behalf, and limited authority is granted to the Collective for this purpose.

PATIENT/MEMBER INITIALS ______

9. I agree and understand that all medicine obtained from the Collective is for medical use only and may not be diverted for non-medical use or for use by a non-member of the Collective. I understand that it is a violation of this agreement and of California law to sell or divert my medical cannabis products in any way and for any reason to any other person and a violation of this section will result in immediate revocation of my membership in the Collective. Also, to prevent diversion of cannabis products to non-members, I understand that the Collective limits disbursement of medicine to no more than eight (8) ounces per month unless specifically authorized by management.

PATIENT/MEMBER INITIALS ______

10. I understand that my medical cannabis recommendation may be disclosed pursuant to any required audits by any Government agency for purposes of verifying the Collective’s compliance with the Compassionate Use Act, Medical Marijuana Program Act, Attorney General Guidelines and/or local ordinance. I understand that the Collective may maintain records of my medical use in order to demonstrate compliance with the Compassionate Use Act, Medical Marijuana Program Act, Attorney General Guidelines and/or local ordinance, and that the Collective will take all legal steps necessary to keep such records private and confidential, subject to the need of the Collective to use such records in order to defend itself and establish that the conduct of the Collective and its members did not violate the law.

PATIENT/MEMBER INITIALS ______

11. As a member of the Collective, I recognize that there are risks inherent in the use of medical cannabis. All medical cannabis is obtained from members of the Collective at various location not necessarily under the Collective’s direct supervision. While the Collective takes every reasonable step and precaution to assure the quality of the medical cannabis, the Collective makes no warranties or representations as to the purity and effectiveness of the medical cannabis products. I understand that the Collective is not responsible for the effects and makes no representation or warranties, express or implied, with regard to the safety, effect or efficacy of the medical cannabis products I may obtain from the Collective when used by itself or with other medicine.

PATIENT/MEMBER INITIALS ______

12. As a member of the Collective, I agree to follow the bylaws, rules and policies of the Collective and I acknowledge I have been provided an opportunity to review the Collective bylaws, rules and policies.

PATIENT/MEMBER INITIALS ______

13. I hereby release, waive and discharge the Collective, including its officers, agents, employees, managers, independent contractors, parent organizations, subsidiaries, affiliates and other personnel (“Releasees”) from, and agree and covenant not to sue Releasees for, any claim, liability, or demand of any kind or on account of any personal injury, temporary or permanent disability, death, property damage, or other damages, whether caused by the negligence of Releasees or otherwise, resulting form or in any way associated with my presence on the premises Collective’s facilities, amenities, or services.

PATIENT/MEMBER INITIALS ______

I declare under penalty of perjury that the information provide on this membership agreement is true and correct. I further declare under penalty of perjury that I am a medical cannabis patient and will not divert my medicine for non-medical use or for use by a non-member. I further declare under penalty of perjury that I am not a member of law enforcement and will not divert any medicine for the purpose of any criminal investigations. I have read and understand the above requirements and agree to follow these guidelines. I acknowledge that I have been offered the ability to review a copy of the Articles of Incorporation, Bylaws and Membership Rules and Policies. Additionally, I hereby authorize the release of my medical information concerning my diagnosis, condition or prognosis to the Collective and its authorized representatives for the purposes of verifying the validity of my medical recommendation and the valid operation of the Collective pursuant to the Compassionate Use Act and Medical Marijuana Program Act Compassionate Use Act and Medical Marijuana Program Act.

SIGNATURE _______________________________________

DATE ______________________________

PRINT CLEARLY TO AVOID ERRORS

Patient’s Information

Last Name: ____________________ Middle: _________________

First Name: _____________________

Over 65 yr: Yes/No Birth Date: _______________

Are you a Veteran: Yes/No

Address: _______________________________________

City: ____________________ Zip: __________

City: ___________________ Cell Phone #: __________________

(Texting Patients w/ Monthly Specials)

CA DL or State ID #: __________________________

Expiration Date: _______________

Physician’s Information

Doctor’s Name: ______________________________________

Phone #: __________________________

Address: _______________________________________

City: ____________________ Zip: __________

City: ___________________

Date of Recommendation: ________________

State ID: _______________________ Expiration Date: ________________

I authorize my recommending physician to verify his or her recommendation or approval for the use of medical cannabis. I certify under penalty of perjury that (1) the information, representations, records and other documents provided to the Collective are true, accurate, complete, without any material omission and (2) I am not seeking membership for any fraudulent purposes.

PATIENT’S SIGNATURE: _______________________________________

DATE: ____________________

PRINT YOUR NAME: _______________________________________

[FOR OFFICE USE ONLY]
Verification of Patient’s Doctor’s Recommendation

Patient received by:
Physician contacted by:
Verified: Yes/No
Date:
Time: [FOR OFFICE USE ONLY]
Verification of Physician’s CA Medical License

Checked by:
Physician’s License #:
Verified: Yes/No
Date:
Time:

NOTICE TO LOCAL LAW ENFORCEMENT: Pursuant to the Constitution of the State of California, Amendment III, Section 3.5©, state enforcement officials do not have the authority to refuse to enforce a statute on the basis that federal law or federal regulations prohibit the enforcement of such statute. Furthermore, in Garden Grove v. Superior Court, the Court of Appeal for the Fourth Appellate District has observed that, “it is not the job of local police to enforce the federal drug laws.”

Thank you so much for your understanding and compliance.

All members are required to have a valid recommendation from a doctor pursuant to Prop. 215, a valid ID, be a California resident and over the age of 18.

MDS is a California nonprofit mutual benefit corporation collective of qualified patients operating within strict compliance of California Health and Safety Code sec. 11362.5 (B)(1)(A), 11362.7 (H), Prop. 215, Senate Bill 420 and CA Attorney General Guidelines.

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