Patient/Caregiver Change of Address Form

I am requesting to change my address on the following registration(s):

Patient Registration

Caregiver Registration

Email ( A copy of this request will be delivered to the email address provided)

Patient Information

Patient ID/License Number

Patient Type

Caregiver Information

Caregiver ID/License Number

Address Information

Do you have an updated valid Maryland State issued Driver License or Identification Card?

Yes

Please upload a copy of your Maryland State issued Driver License or Identification Card.

Click Here to Upload

Do you have a Maryland Motor Vehicle Administratin (MVA) Change of Address Card?

Yes

Please upload a copy of the MVA change of address card

Click Here to Upload

Please provide two of the following documents as proof of your current Maryland address:

Note: All documents must be dated within the past 90 days; each must include the applicant's name, date, and address; and must not be from the same agency such as two documents issued by MVA)

MVA registration card
Car title
MVA change of address card
Utility, telephone or cable/satellite TV bill
Bank account statement
Property tax bill
Mortgage statement or proof of home ownership (Deed, Title, Bill of Sale)
Major credit card bill (Visa, MasterCard, Wal-Mart, Target, etc.)
Residential rental contract (lease or rental contract between landlord and tenant which includes all signatures).
Selective Service Card
Federal, state or local government mail issued by the state of Maryland (Example: Social Security, social services documents, child support)
Car insurance policy
Paystubs (dated within 90 days)
W-2 statements from previous year.
State of Maryland Health Insurance issued documents (Example: Medicaid, Medicare, Maryland Health Connection)

Upload proof of current address (1/2)

Click Here to Upload

Upload proof of current address (2/2)

Click Here to Upload

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I authorize the Maryland Cannabis Administration to change my Patient/Caregiver Address.