Welcome to New Jersey Medical Marijuana Registry Homepage!

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 Health Care Practitioner Registration
 Personal Information
Last Name:
 First Name:
 Middle Name:
Date of Birth:
 
 Office Contact Information
Street1:
 Street2:
City:
 County:
 Municipality:
 State:   Zip:
   
Phone:
- -  Ext 		Fax:
- -
Alternate Phone:
- -  Ext 		Email:
 
 License Information
CDS Number:
 License Number:
NJ Medical Licensure Type:
 Issuing State:
 
Address as on license:             Same as contact address
Street1:
 Street2:
City:
 State:                                Zip:
        
 
 
 User Access Information
Password is case-sensitive and must be 8-15 characters in length with at least one number or special character.
Desired User Name:
 Password:
 Re-type Password:
Secret Question:
 Secret Answer:
 
 Health Care Practitioner Agreement
  By submitting this form I accept the above Health Care Practitioner Agreement.
 
 Applicant Information
Applicant's Last Name:
 Applicant's First Name:
 Applicant's Title:
 
  This practice is not accepting new patients.
 
  Check here if you prefer that your name/practice not be publicly listed on our website.
 
     
Required Field