___________________________________________________________________________________________________________________________________ State of Vermont Department of Public Safety Marijuana Registry [phone] 802-241-511545 State Drive [fax] 802-241-5230Waterbury, Vermont 05671-1300 [email] DPS.MJRegistry@vermont.gov

VERMONT MARIJUANA REGISTRY Newsletter

Bennington Dispensary Opening PhytoScience Institute (PSI) D.B.A. PhytoCare Vermont is anticipated to open April 17th, 2018 in Bennington. Information about PhytoCare Vermont has been enclosed to provide you with information regarding their operations and products.

If you want to designate PhytoCare Vermont to purchase usable marijuana products and/or seeds and clones, you MUST complete and submit the enclosed form to the Registry. If you want to stay with your current designated dispensary do NOT complete and submit the enclosed form. Remember you may only designate one dispensary. There is no fee required for completing the enclosed form, if the form is received by the Registry on or before April 30th, 2018. Completed forms may be mailed to the Vermont Marijuana Registry at 45 State Drive, Waterbury, VT 05671-1300 or emailed to DPS.MJRegistry@vermont.gov. A new registry ID card will be mailed to the address provided, if you are designating a new dispensary.

ADDITIONAL INFORMATIONSouthern Vermont Wellness will be opening a second dispensing location in Middlebury. This location is expected to open for patient appointments in May 2018. Further details about this location will be sent prior to the opening of this dispensing location.

New applications and forms are NOW available on our new webpage: MedicalMarijuana.Vermont.Gov

Please ensure when renewing you are submitting the most up-to-date form(s) to reduce your processing time.

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PhytoCareVERMONT

PhytoCareVERMONT

State of Vermont Department of Public Safety Marijuana Registry [phone] 802-241-511545 State Drive [fax] 802-241-5230Waterbury, Vermont 05671-1300 [email] DPS.MJRegistry@vermont.gov

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PATIENT DESIGNATION OF DISPENSARY FORMInstructions: Current cardholders who have already designated a dispensary and want to cultivate MUST complete this form. Additionally, current cardholders who are cultivating and would like to purchase usable products, and/or seeds and clones from a dispensary MUST complete this form. Note: No fee is required.

1. FULL LEGAL NAMELast _______________________________ First _______________________________ M.I. _________

2. REGISTRY ID NUMBER (As shown on current ID card): ________________________________________

3. CONTACT INFORMATION

Mailing Address: ______________________________________________________________________________

City, State, Zip: _______________________________________________________________________________

Physical Address (if different than mailing): _________________________________________________________

City, State, Zip: _____________________________________ Telephone Number: _________________________

4. DISPENSARY DESIGNATION (Select only ONE dispensary)

Champlain Valley Dispensary (Burlington) Grassroots Vermont (Brandon)

PhytoCare Vermont (Bennington) Southern Vermont Wellness (Brattleboro)

Vermont Patients Alliance (Montpelier)

5. DISPENSARY COMMUNICATION & DELIVERY (Dispensaries are REQUIRED to maintain ALL patient andcaregiver information as confidential in conformity with HIPAA. This authorization may be withdrawn at any time.)

May the Vermont Marijuana Registry (VMR) provide your address, phone number, and email (if applicable) to yourdesignated dispensary? Yes No(By checking Yes you will be eligible to receive delivery and your dispensary will be able to contact you about yourappointment(s), if needed. ONLY the VMR and your dispensary will have your information.)

6. CULTIVATION

Do you plan on cultivating marijuana in the next 12 months? Yes No If you selected Yes, the section below MUST be completed.

Secure Indoor Facility Information: Physical address (where marijuana will be cultivated): ___________________________________________________

Location within building: ________________________________________________________________________

I declare under pains and penalty of perjury that the information provided on this form in its entirety is true and accurate.

SIGNATURE: ____________________________________________________________ DATE: _________________________

------------------------------------------------------------------------------------------------------------------------------------------------------------- OFFICE USE ONLY: Processed: Date: ____________ Initials: _____________ Notes: _________________________________________

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Submit to Registry by April 30, 2018