ASSOCIATE MEMBERSHIP AGREEMENT OF GOLDEN STATE HEALTH AND WELLNESS, INC. A California Nonprofit Mutual Benefit Corporation (for an individual) l, , hereby declare under penalty of perjury under the laws of the State of California that: 1. I am a California resident who is at least 18 years of age; 2. I have a valid California issued Driver's License or identification Card; 3. I have a valid written approval or recommendation by a licensed California physician to use medical cannabis for my documented medical condition(s). As a qualified medical cannabis patient protected by California law, you are required to read and to agree with the following statements to become an Associate Member of Golden State Health and Wellness, Inc., a California nonprofit mutual benefit corporation (hereinafter, the "Collective"). After reading the following statements, please sign and date in the space provided below to certify that you have read, understood, and that you agree with each statement, and that you agree to abide by the terms of this Agreement, the Bylaws of the Collective, and all policies and procedures of the Collective. I. I understand that the Collective consists of qualified medical cannabis patients who are residents of the State of California and who have voluntarily joined together to share resources in connection with the cultivation, transportation and distribution of medical cannabis for each other's respective medical condition(s). As a qualified patient, I choose to become an Associate Member of the Collective, II. hereby appoint and designate the Collective and its representatives as my true and lawful agents for the limited purpose of assisting me in my medical cannabis needs. I understand this means that the Collective, by and through its members, may cultivate, purchase, possess, transport and distribute medical cannabis to me, with me, or from me (as applicable) and I grant them the authority to do so. III. I understand that the Collective intends to operate in full compliance with all applicable California laws, and I agree to not take any actions which may cause violations of such laws or otherwise jeopardize the ability of the Collective to operate. IV. I understand that all application fees (if applicable) and membership fees (if applicable) paid to the Collective will be used by the Collective to reimburse for actual expenses and reasonable costs associated with the operation of the Collective. In addition, I understand that in order to remain a viable nonprofit entity the Collective must charge its members for medical cannabis, and that the Collective will only charge an amount that allows for it to cover its actual expenses and reasonable costs associated with the operation of the Collective, including all overhead expenses, a reasonable salary for any one or more of its officers as determined by the Board of Directors of the Collective, and an appropriate amount of reserve funds to be used for improvements to the Collective's operations, emergencies, repairs, or as Otherwise determined by the Board of Directors of the Collective. Page 1 of 3
Page 2 of 3V. I agree to provide any valid California physician's recommendation for medical cannabis use and ray valid California Driver's License or California Identification Card to a representative of the Collective each and every time I obtain medical cannabis from the Collective, provide medical Cannabis to the Collective, or otherwise engage in any dealings with the Collective or its members pertaining to Cannabis, In addition, I authorize the Collective to make photocopies of such documents and to keep such photocopies with the Collective's business records, which may be digital physical, or both. I acknowledge that the Collective will attempt to keep Such personal information confidential, but may be required by law, court, order, or otherwise to reveal any or ail of Such information to third parties, including local, state, and/or federal authorities, VI. I agree that only I or Iny designated caregiver (who must also be a member of the Collective) will interact with the Collective in regards to obtaining medical cannabis from the Collective, providing medical cannabis to the Collective, or otherwise engaging in any dealings with the Collective or its members pertaining to cannabis, VII. I agree to not share, sell or distribute any medical cannabis I obtain through the Collective with any person or entity who is not a member of the Collective. VIII. I understand that the Collective requires that I provide my current and valid email address for purposes of the Collective providing me with notices of meetings, events, and other information, and I agree to the terms of the Consent to Electronic Transmission document which I have signed and included herewith. IX. I agree that no photos, video recordings, weapons, illegal drugs or dangerous activities are permitted at any location owned, leased or controlled by the Collective. X. hereby authorize my California physician who recommended that I use medical cannabis to release my personal healthcare information concerning my medical diagnosis, condition, and medical cannabis recommendation to the Collective, I acknowledge that the Collective will attempt to keep such personal healthcare information confidential, but may be required by law, court order, or otherwise to reveal any or all of such information to third parties, including local, state, and/or federal authorities, XI. Η I agree to promptly contact the Collective if there are any changes to my contact information, primary caregiver (if applicable), or the status of my medical cannabis recommendation. Member Name: Member Signature: Date: E-Mail Address: Recommending Physician Information (name and address): Expiration Date of Recommendation (if applicable): Required Attachments: ● Copy of physician's recommendation for use of medical cannabis ● Copy of valid California issued Driver's License or identification Card ● Signed Consent to Electronic Transmission form Page 2 of 3
Page 3 of 3GOLDEN STATE HEALTH AND WELLNESS, INC, A California Nonprofit Mutual Benefit Corporation CONSENT TO ELECTRONIC TRANSMISSION (individual member) As a member (or prospective member, if your application is pending review and approval) of Golden State Health and Wellness, Inc., a California nonprofit mutual benefit corporation (the "Corporation"), you must provide your written consent in order to receive official communications from, and to send official communications to, the Corporation via electronic transmission (fax or email). This consent form will allow the Corporation to send you meeting notices, ballots, conduct meetings, and handle other official business pertaining to the Corporation, by electronic transmission (i.e. fax or email). It also allows you to send important information to the Corporation via fax or email. Before signing this consent form, please review and be aware of the following: 1. You are not required to sign this form. You may request that meeting notices, ballots, and other matters of official business be sent to you via regular mail, 2. You have the right to withdraw your written consent at any time after signing this form by providing the Corporation with written notice that you are withdrawing your consent relative to electronic transmission. This consent to electronic transmission is broad, and may include transmission of meeting notices, ballots, and other important information regarding the Corporation. 3. This consent form represents consent under California Corporations Code Sections 20 and 21 (transmissions from and to the Corporation) as well as under the federal Electronic Signatures in Global and National Commerce Act (15 U.S.C. S. 7001(c)(1)). 4. Consenting to electronic transmissions indicates that you are capable of Sending and receiving emails and/or facsimiles and agree to present your current email address and/or fax number to the Corporation, providing updates as changes occur. The undersigned has read and understands the foregoing, and hereby provides this unrevoked written consent to receive and send information, including but not necessarily limited to meeting notices, ballots, and other information regarding the Corporation, via electronic transmission (fax and/or email), until Such time as this consent is revoked in writing. You may choose both email and fax or just one of them below. Name: Signature: Date: Facsimile number: E-mail address: Please return a signed original or copy of this completed form to the Corporation through any of its officers or agents authorized to receive this form.