Order Request Form - Agrima Botanics

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Order Request Form
Administrative Information (To be completed by department)
Receive Date
Approval Date
Refusal Date (if applicable)
Order Number
Order Recorded by (Print Name, Signature and Date)
Section A - Client Information (To be completed by client)
Given Name
Surname
Date of Birth
Unique Identifier (if applicable)
Shipping Address
Postal Code
Telephone Number
Email Address
Do you have an individual responsible for you?
 No
 Yes
If yes complete Section B and C; If no complete Section C
Are you a pharmacist practising in the hospital or a health care
 No
 Yes
practitioner authorized to place orders for that substance on behalf of
the hospital? If yes complete Section C
 No
Are you a client on the basis of a registration with the Minister made
 Yes, to obtain interim supply
under Production for Own Medical Purposes and Production by a
 Yes, to obtain starting material
Designated Person? If yes complete Section D
 Yes, to obtain both interim supply and starting material
Are you an authorized representative of one of the following?  Licensed Producer  Licensed Dealer
 the Minister
 a person to whom an exemption granted by the Minister
If yes complete Section F
Section B - Biographical Information (To be completed by individual placing the order if applicable)
Given Name
Surname
Section C - Order Details (To be completed by client/hospital employee)
 Dried Marihuana
Name of the
Quantity
Brand Name
 Fresh Marihuana
substances
 Cannabis Oil
Section D - Order Details (To be completed by client with Registration Certificate issued by the Minister)
 Dried Marihuana (interim supply)
Name of the
Quantity
Brand Name
 Fresh Marihuana (interim supply)
substances
 Cannabis Oil (interim supply)
 Marihuana Plants (starting material)
 Marihuana Seeds (starting material)
 Other; Please specify_____________
Section E - Order Details (To be completed by Licensed or Exempt Party/the Minister)
 Dried Marihuana
Name of the
Quantity
Brand Name
 Fresh Marihuana
substances
 Cannabis Oil
 Marihuana Plants
 Marihuana Seeds
 Other; Please specify_____________
Important Notice
The shipping address indicated in this form must be the same shipping address in the Client Registration Completion Notification.
If more than 30 days have elapsed since the date the order was placed, the order must be refused. Please provided the completed Order
Request Form as soon as possible once signed and dated.
Completed by (Print Name):
Signature:
Date (DD/MM/YYYY):
FRM 021
Page 1 of 1
Order Request Form
Printed on: 08/01/18
Order Request Form
Administrative Information (To be completed by department)
Receive Date
Approval Date
Refusal Date (if applicable)
Order Number
Order Recorded by (Print Name, Signature and Date)
Section A - Client Information (To be completed by client)
Given Name
Surname
Date of Birth
Unique Identifier (if applicable)
Shipping Address
Postal Code
Telephone Number
Email Address
Do you have an individual responsible for you?
 No
 Yes
If yes complete Section B and C; If no complete Section C
Are you a pharmacist practising in the hospital or a health care
 No
 Yes
practitioner authorized to place orders for that substance on behalf of
the hospital? If yes complete Section C
 No
Are you a client on the basis of a registration with the Minister made
 Yes, to obtain interim supply
under Production for Own Medical Purposes and Production by a
 Yes, to obtain starting material
Designated Person? If yes complete Section D
 Yes, to obtain both interim supply and starting material
Are you an authorized representative of one of the following?  Licensed Producer  Licensed Dealer
 the Minister
 a person to whom an exemption granted by the Minister
If yes complete Section F
Section B - Biographical Information (To be completed by individual placing the order if applicable)
Given Name
Surname
Section C - Order Details (To be completed by client/hospital employee)
 Dried Marihuana
Name of the
Quantity
Brand Name
 Fresh Marihuana
substances
 Cannabis Oil
Section D - Order Details (To be completed by client with Registration Certificate issued by the Minister)
 Dried Marihuana (interim supply)
Name of the
Quantity
Brand Name
 Fresh Marihuana (interim supply)
substances
 Cannabis Oil (interim supply)
 Marihuana Plants (starting material)
 Marihuana Seeds (starting material)
 Other; Please specify_____________
Section E - Order Details (To be completed by Licensed or Exempt Party/the Minister)
 Dried Marihuana
Name of the
Quantity
Brand Name
 Fresh Marihuana
substances
 Cannabis Oil
 Marihuana Plants
 Marihuana Seeds
 Other; Please specify_____________
Important Notice
The shipping address indicated in this form must be the same shipping address in the Client Registration Completion Notification.
If more than 30 days have elapsed since the date the order was placed, the order must be refused. Please provided the completed Order
Request Form as soon as possible once signed and dated.
Completed by (Print Name):
Signature:
Date (DD/MM/YYYY):
FRM 021
Page 1 of 1
Order Request Form
Printed on: 08/01/18

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