(b) A facility or natural person selected by a certified patient as a designated caregiver may apply to the department for a registry identification card or renewal of such card on a form or in a manner determined by the department. The proposed designated caregiver shall submit an application to the department which shall contain the following information and documentation:

1. (1) For a proposed designated caregiver that is a natural person, the individual shall submit:

   1. (i) the applicant’s full name, address, date of birth, telephone number, email address if available, and signature;
   2. (ii) if the applicant has a registry identification card, the registry identification number;
   3. (iii) a nonrefundable application fee of $50, provided, however that the department may waive or reduce the fee in cases of financial hardship as determined by the department;
   4. (iv) a statement that the applicant is not the certified patient’s practitioner;
   5. (v) a statement that the applicant agrees to secure and ensure proper handling of all approved medical marihuana products;
   6. (vi) acknowledgement that a false statement in the application is punishable under section 210.45 of the Penal Law;

   7. (vii) proof that the applicant is a New York State resident, consisting of a copy of either:

      1. (a) a New York State issued driver’s license; or
      2. (b) a New York State non-driver identification card;
   8. (viii) if the documentation submitted by the applicant in accordance with subparagraph (vii) of this paragraph does not contain a photograph of the applicant or the photograph on the documentation is not a true likeness of the applicant, the applicant shall provide one recent passport-style color photograph of the applicant’s face taken against a white background or backdrop. The photograph shall be a true likeness of the applicant’s appearance on the date the photograph was taken and shall not be altered to change any aspect of the applicant’s physical appearance. The photograph shall have been taken not more than 30 days prior to the date of the application. The photograph shall be submitted in a form and manner as directed by the department, including as a digital file (.jpeg);
   9. (ix) identification of all certified patients for which the applicant serves, has served or has an application pending to serve as a designated caregiver and a statement that the applicant is not currently a designated caregiver for five current certified patients, and that he/she has not submitted an application which is pending and, if approved, would cause the applicant to be a designated caregiver for a total of five current certified patients.

2. (2) For a proposed designated caregiver that is an entire facility that is licensed or operated pursuant to an authority set forth in section 1004.3(k) of this Part, the designated caregiver shall submit:

   1. (i) the facility’s full name, address, operating certificate or license number where appropriate, email address, and printed name, title, and signature of an authorized facility representative;
   2. (ii) if the facility has a registry identification card, the registry identification number;
   3. (iii) a statement that the facility agrees to secure and ensure proper handling of all approved medical marihuana products; and
   4. (iv) an acknowledgement that a false statement in the application is punishable under section 210.45 of the Penal Law;

3. (3) For a proposed designated caregiver that is a division, department, component, floor or other unit pursuant to section 1004.3(k) of this Part, the designated caregiver shall submit:

   1. (i) the parent facility’s full name, address, operating certificate or license number where appropriate, email address, and printed name, title and signature of an authorized representative of the parent facility and of an authorized representative of the division, department, component, floor or other unit;
   2. (ii) if the parent facility, division, department, component, floor or other unit has a registry identification card, the registry identification number;
   3. (iii) a statement that the parent facility, and the division, department, component, floor or other unit, agree to secure and ensure proper handling of all approved medical marihuana products; and
   4. (iv) an acknowledgement that a false statement in the application is punishable under section 210.45 of the Penal Law.

(h) The department shall deny a registry identification card for an applicant who:

1. (1) is already a designated caregiver for five currently certified patients or has an application pending that, if approved, would cause the proposed designated caregiver to be a designated caregiver for more than five currently certified patients; or
2. (2) in accordance with subdivision (e) of this section, fails to provide complete or factually accurate information in support of his or her initial or renewal application.