LET’S GET STARTEDOnce we have all of your information, we’ll tell you about our 1st Time Patient Deals. Step 1 Your Info First Name*Last Name*Email* Phone*Your County?*RiversideSan DiegoUnknownPassword* Enter Password Confirm Password Strength indicator Step 2 Your Creds Please Provide active credentials (Expired creds are not acceptable) Drivers License #*State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Rec. Number*Rec. Expiration Date* MM DD YYYY Upload a Photo of your ID & Rec.* Drop files here or Accepted file types: jpg, png, pdf. Step 3 Terms & Agreement Membership AgreementI hereby declare under penalty of perjury under the laws of the State of California that: I am a California resident over the age of 18, have a valid state issued Driver's License or Identification Card and a valid written approval by a licensed California physician to use medical marijuana for my documented medical condition(s). As a qualified patient protected by California law (Health and Safety Code §11362.5 and §11362.7, et seq., CA SB420), you are required to read and to agree with the following statements to become a member of Alpha Medic Inc., a California non-profit association. After reading the following statements, please select "I Agree To This Membership Agreement" in the checkbox below. This will certify that you have read, understand and agree with each statement. I have read, understand and agree to each of the following: I understand that Alpha Medic Inc. is a California non-profit association of qualified patients who voluntarily joined together to share resources and cultivate medical marijuana for each other’s respective medical condition(s). As a qualified patient I choose to become a member of Alpha Medic, Inc., Inc. I understand that Alpha Medic Inc., Inc. was established to provide a professionally administered and legally structured collective for the benefit of all its members. As a member, I appoint and designate Alpha Medic Inc. and their representatives as my true and lawful agents for the limited purpose of assisting in obtaining medical marijuana. I understand this means Alpha Medic Inc. may be required to purchase, possess, and distribute my medication to me and I grant them authority to do so. I understand that Alpha Medic Inc. operates within full compliance of all applicable California laws relating to the cultivation, possession, transportation and use of medical marijuana. I understand that all donations made Alpha Medic Inc. are to be used to reimburse for actual expenses and reasonable costs for the administration of the collective. Furthermore, all donations are for the continued operation of the collective and that any said donation in no way constitutes a commercial promotion or sale of any item. I agree to provide my valid California physician's recommendation for medical marijuana use and California Driver's License or California Identification Card to driver each and every time I obtain medical marijuana. I agree that only myself, or my designated caregiver will interact Alpha Medic Inc. I agree to not share, sell or distribute any medical marijuana I obtain Alpha Medic Inc. I agree that no phones, still photos, video recording equipment, weapons, illegal drugs or activities are allowed at the collective location. I hereby authorize my treating California doctor who recommended medical marijuana use, as required by state and federal laws including HIPPA regulations, to release my medical marijuana information concerning my diagnosis, condition, and/or prescription to Alpha Medic Inc. I agree to notify Alpha Medic Inc. if there are any changes to my address, phone number, physician, caregiver or email. I understand this is a bi-lateral Membership Agreement. Either myself Alpha Medic Inc. may terminate this Membership Agreement at any time by email, without notice or reason and the other party to this Membership Agreement has absolutely no recourse or basis to re-instate the Membership Agreement or any case of action. Please Certify* I Agree To This Membership Agreement This iframe contains the logic required to handle AJAX powered Gravity Forms.