Collective Application Form

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Collective Membership Application Form

Collective Membership has its perks! Not only do you gain access to the Members Only section but also to HUGE discounts on cannabis products! Up to 60% off retail!!!

Valid Medical Marijuana Card Required.
Don't have a card yet? We can help [Click Here]

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First Name *

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Last Name: *

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Date of Birth (mm/dd/yyyy): *

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Email Address (please verify): *

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Phone Number:

Do you have a valid Medical Marijunana Card? *

Yes
No

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Your Patient ID Number *

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Name of your prescribing physician (First and Last name): *

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Physician Phone Number (must be valid): *

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Date of your recommendation (mm/dd/yyyy): *

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Medical conditioning requiring medication: *

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Referral Source:

I will not distribute any of the cannabis I receive from the Sacsterdam Medical Cannabis Collective to any non-members and;

I will not use the cannabis I receive from the Sacsterdam Medical Cannabis Collective for any uses other than medical and;

My medical marijuana identification card is current, and I will immediately inform the Sacsterdam Medical Cannabis Collective if it expires or is revoked and;

I have never diverted medical marijuana for non-medical uses, and will not do so in the future;

I have never been convicted of a narcotics or narcotics distribution related offense.

I agree and certify the above is true * Yes No

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