RxOIL

First Name*	Last Name
Street*	City*
State*	Country
Postal Code*	Phone*
Email*
Dr's Name*	Dr's Phone*
Rec Number*	Rec. Expiration*
Driver's License Number*	Driver's License Expiration*
California Photo Identification*
Your Dr's Medical Cannabis Rec.*
I certify that the following is true:
1) I am a California Resident over 18 years of age.
2) I have a valid medical marijuana recommendation.
3) I will use all cannabis products for my own personal use.
4) I have read and accept the terms and conditions.
Signature (Type Full Name)

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We will contact you to confirm your membership.

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