Join – H32B DEMO

This is a demo of ourGravity Forms User Registrationimplementation for medical marijuana dispensaries.

Join for Los Angeles medical marijuana delivery and enjoy the convenience of online ordering. All patients must have a valid doctor’s recommendation and driver’s license to join our collective and receive medical marijuana delivery services.

You may also contact us directly at (555) 555-5555 to send your information via text or call to make other arrangements; pre-delivery verification may be available to potential patients upon request.

1Membership Applicant Information

2Membership Agreement

Email*
Enter Email Confirm Email
Password*
Enter Password Confirm Password
Strength indicator

Please use a strong password to improve the security of your account.
Name*
First Last
Phone*
Date of Birth*
Month
Day
Year
Driver's License or State ID #*
MMJ Recommendation #*
Expiration of Recommendation*
Month
Day
Year
Address*
Street Address Address Line 2 City State ZIP Code
Driver's License / Passport / State-issued ID*
Accepted file types: pdf, jpg, jpeg, png, tiff, Max. file size: 8 MB.
Please scan and upload your driver's license or state-issued ID card.
Max file size 8MB. Allowed file extensions: .pdf, .jpg, .jpeg, .png, .tiff
CA Physician's Statement & Recommendation*
Accepted file types: pdf, jpg, jpeg, png, tiff, Max. file size: 8 MB.
Please scan and upload an image of your CA Physican's Statement and Recommendation.
Max file size 8MB. Allowed file extensions: .pdf, .jpg, .jpeg, .png, .tiff
Terms & Conditions*
- I have read and agree to the Terms & Conditions and Privacy Policy

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DIGITAL SIGNATURE - Full Name*
By typing your full name, you agree to the section above in its entirety.
Date*
Month
Day
Year
Please enter today's date.
How did you hear about us?*
Email
This field is for validation purposes and should be left unchanged.

New Patients Get Gifts!

Free Next Day Delivery in CA