"Medical Cannabis License Id Card Request" - New Mexico

This ""medical Cannabis License Id Card Request" - New Mexico" is a part of the paperwork released by the New Mexico Department of Health specifically for New Mexico residents.

The latest fillable version of the document was released on April 9, 2018 and can be downloaded through the link below or found through the department's forms library.

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Download "Medical Cannabis License Id Card Request" - New Mexico

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MCP License Identification Card Request
Please print clearly - This form will be returned to the business
without further processing if any portion is left blank or if required
forms are not provided.
THIS FORM MUST BE COMPLETED BY THE BUSINESS AND APPLICANT
Applicant First Name: ________________________
Last: ______________________________ MI: __________
Employee Date of Birth: (for verification in case of duplicate names) _______/________/__________
(MM/DD/YY)
Date of Hire: __________/________/____________ (MM/DD/YY)
Status of Applicant:
________Paid Employee
_________Board Member
________Volunteer
Position/Job Duty: (Board member, sales, CDP, testing, etc.) __________________________________________________
Business Name: ______________________________________________________________________________________
Business Representative Completing Application: ___________________________________________________________
Mailing Address of Business: ___________________________________________________________________________
Contact Number: ____________________________________________
MCP ID Checklist
Please ensure all items are included when submitting application
After application has been filled out, send to:
 Photocopy of Identification
Department of Health
 State Criminal Background Check
Medical Cannabis Program
 Nationwide Criminal Background Check
5301 Central Ave N.E. Ste. 204
Albuquerque, NM 87108
 HIPAA Certification
 Food handler safety certificate- if applicable
 If the applicant represents, consults, works, volunteers, or contracts with another Licensed business, list the name of each below:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Employee candidates are NOT authorized to work or perform any services for LNPP, laboratory, manufacturer or courier
until application has been approved and ID card has been issued to employee by the DOH/MCP. NMAC 7.34.4.8 (H)
By signing below the business accepts :
1. acknowledgment that the employee will NOT begin work until ID card has been issued.
2. the identification card is the property of the Medical Cannabis Program
3. the ID card will be immediately returned to the MCP upon separation from the business.
Applicant Signature: ___________________________________________________
Date: ________________________
Authorized Business Representative: ______________________________________ Date: _________________________
NMDOH USE ONLY
Review Date: ____________________
 Approved
 Not Approved
MCP Staff Member / Manager Signature: ____________________________________ Date: ________________
Revised:
04/09/2018
MCP License Identification Card Request
Please print clearly - This form will be returned to the business
without further processing if any portion is left blank or if required
forms are not provided.
THIS FORM MUST BE COMPLETED BY THE BUSINESS AND APPLICANT
Applicant First Name: ________________________
Last: ______________________________ MI: __________
Employee Date of Birth: (for verification in case of duplicate names) _______/________/__________
(MM/DD/YY)
Date of Hire: __________/________/____________ (MM/DD/YY)
Status of Applicant:
________Paid Employee
_________Board Member
________Volunteer
Position/Job Duty: (Board member, sales, CDP, testing, etc.) __________________________________________________
Business Name: ______________________________________________________________________________________
Business Representative Completing Application: ___________________________________________________________
Mailing Address of Business: ___________________________________________________________________________
Contact Number: ____________________________________________
MCP ID Checklist
Please ensure all items are included when submitting application
After application has been filled out, send to:
 Photocopy of Identification
Department of Health
 State Criminal Background Check
Medical Cannabis Program
 Nationwide Criminal Background Check
5301 Central Ave N.E. Ste. 204
Albuquerque, NM 87108
 HIPAA Certification
 Food handler safety certificate- if applicable
 If the applicant represents, consults, works, volunteers, or contracts with another Licensed business, list the name of each below:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Employee candidates are NOT authorized to work or perform any services for LNPP, laboratory, manufacturer or courier
until application has been approved and ID card has been issued to employee by the DOH/MCP. NMAC 7.34.4.8 (H)
By signing below the business accepts :
1. acknowledgment that the employee will NOT begin work until ID card has been issued.
2. the identification card is the property of the Medical Cannabis Program
3. the ID card will be immediately returned to the MCP upon separation from the business.
Applicant Signature: ___________________________________________________
Date: ________________________
Authorized Business Representative: ______________________________________ Date: _________________________
NMDOH USE ONLY
Review Date: ____________________
 Approved
 Not Approved
MCP Staff Member / Manager Signature: ____________________________________ Date: ________________
Revised:
04/09/2018
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