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Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Samoa
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7
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8
Have you been experiencing Chronic Pain for 12 months or more?
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Must answer Yes to be qualified for a Medical Marijuana card today
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9
What part of the body are you experiencing your chronic pain?
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10
How long have you been experiencing this pain?
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Must be at least 12 month or greater to qualify
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11
Using the scale from 1-10 please rate what level your pain is.
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12
Do you currently receive EBT/ Foodstamps?
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13
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16
Signature
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I attest that I will not divert marijuana to any individual who or entity that is not allowed to possess marijuana pursuant A.R.S. Title 36, Chapter 28.1 and that the information provided in the application is true and correct.
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