Become a Member

There is a screening process for all new patients. (All applicants are not guaranteed access.)
Thank you for your interest in joining 1105 Cooperative. This is the first step to becoming a member of our Cooperative. To complete the form, you will need to scan and attach two pictures: your California Driver’s License/ID card and your Doctor’s Recommendation. If you do not have access to a scanner, you can take pictures of the documents with your smart phone and upload them. If you are having technical difficulties, you can also email your documents to 1105coop@gmail.com.

Submitting blurry or indecipherable documents will delay your application process.
Please make sure the pictures are legible and under 5MB.

Double check and make sure all information you input is correct.
After you complete your application, we verify your information. If your application is not filled out completely it gets moved to a hold list, which will cause delays.

CA Drivers License or CA ID Card (required)

Doctors Recommendation (required)

Your (FIRST) Name (required)

Your (LAST) Name (required)

Date of Birth (required)

Main Phone Number (required)

Your Email (required)

RETYPE Your Email (required)

Address / City / State / ZIP (required)

Conditions & Symptoms: (required)

Doctor’s Recommendation Authorization Number: (required)

Initial Date of Doctor’s Recommendation: (required)

Expiration Date of Doctor’s Recommendation: (required)

Doctor’s Name: (required)

Clinic Phone Number: (required)

California Driver’s License or ID Number: (required)

California Driver’s License or ID Number Expiration Date: (required)

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 I have read and accept the Member Application and Agreement, Disclaimer and Terms & Conditions listed below.

 

Disclaimer and Terms & Conditions

I hereby agree to the terms and represent that I am a qualified patient, entitled to cultivate, process, possess, transport and utilize medical marijuana. I am applying for membership int eh 1105 COOPERATIVE INC and hereby delegate to the Cooperative my rights to cultivate, process, posses such quantities are allowed under the laws of the State of California for my benefit and the benefit of its members. This delegation of rights can be taken back by the patient at any time either in whole or in part upon reasonable written notice to the Cooperative by the member. This notice can be either emailed, faxed, or delivered to the Cooperative distribution center.

I am a qualified patient protected by California Law Health and Safety code 11362.7 et. seq. and 11362.5 et. seq. My doctor has recommended in writing and approved my use of medical marijuana and will review my case on at least a yearly basis. I am legally entitled to use, possess, transport, and cultivate medical marijuana cooperatively through safe and affordable access pursuant to Health and Safety Code 11362.775, I agree to follow all rules and guidelines of the Cooperative and pay reasonable compensation and or contribute time services medicine in return for membership services and goods provided by the Cooperative.

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