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Ion requirements of the Oregon Medical Marijuana Act. Attach legible copies of ID and enclose your payment. If applicant is a minor (under 18), the custodial parent or legal guardian with responsibility for health care decisions must be listed as the Primary Caregiver. PLEASE TYPE OR PRINT LEGIBLY. APPLICANT INFORMATION (REQUIRED) A NAME (LAST, FIRST, M.I.): Male Female MAILING ADDRESS: DATE OF BIRTH: PHONE #: CITY: STATE: Oregon COUNTY: ZIP CODE: Photo Identification: A photocopy o.

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