INSTRUCTIONS: ALABAMA APPLICATION FOR REINSTATEMENT OF PHYSICIAN ASSISTANT/ANESTHESIOLOGIST ASSISTANT LICENSE

To apply for a reinstatement of a physician assistant or anesthesiologist assistant license in Alabama, use the form discussed in this article. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 1: On line 1, enter your name.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 2: On line 2, enter your address.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 3: On line 3, enter your initial license number and the date on which it was issued.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 4: On line 4, enter the date of revocation, suspension or surrender of the license.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 5: On line 5, enter your Social Security number and date of birth. 

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 6: On line 6, provide a detailed explanation of the reasons for the revocation, suspension or surrender of your license. If necessary, this may be continued on an additional sheet of paper.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 7: Answer questions 1 through 7 by checking "Yes" or "No" as applicable.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 8: Answer questions 2 through 4 by checking "Yes" or "No" as applicable. If you answer yes to question 4, attach a list with the name and principal practice location of each primary supervising physician to whom you are certified in another state.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 9: Answer questions 5 and 6 at the bottom of the first page by checking "Yes" or "No" as applicable.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 10: On the second page, answer questions 6 through 12 by checking "Yes" or "No" as applicable.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 11: Enter your signature where indicated.

Alabama Application For Reinstatement Of Physician Assistant/Anesthesiologist Assistant License Step 12: List all states in which you hold or have applied for licensure. Have the form certified by a notary public.

ALABAMA BOARD OF LICENSURE FOR PROFESSIONAL GEOLOGISTS FORM FOR PERSONAL REFERENCE

As part of the process to be licensed as a professional geologist in Alabama, the personal reference form discussed in this article must be discussed. This document can be obtained from the website maintained by the Alabama Board of Licensure for Professional Geologists.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 1: Enter your name on the first blank line.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 2: Enter your address on the next two blank lines.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 3: Enter your signature and the date on the next two blank lines.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 4: The remainder of the form should be completed by the person providing the reference. On the line 1, they will enter their name.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 5: On line 2, the person providing the referral will enter their address and telephone number.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 6: On line 3, the person providing the referral will enter how long they have known you both personally and professionally.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 7: On line 4, the person providing the referral will indicate with check marks what kind of personal relationship they have with you.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 8: On line 5, the person providing the referral will evaluate your personal honesty and integrity with check marks.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 9: On line 6, the person providing the referral will indicate with check marks if they know of any instances in which you were convicted of illegal conduct or misconduct. If so, they must provide an explanation on a separate sheet.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 10: On line 7, the person providing the referral will enter any additional information and comments they feel are pertinent.

Alabama Board Of Licensure For Professional Geologists Form For Personal Reference Step 11: The person providing the referral will sign and date the form.

INSTRUCTIONS: ALABAMA BOARD OF LICENSURE FOR PROFESSIONAL ENGINEERS AND LAND SURVEYORS COMPLAINT FORM 

To file a complaint against an Alabama professional engineer, land surveyor, or engineering or land surveying firm, use the document discussed in this article. This form may be obtained from the website of the Alabama Board of Licensure for Professional Engineers and Land Surveyors.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 1: Enter the date on which the complaint is being filed.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 2: In section 1, provide your name, address, home and work telephone numbers and email address.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 3: In section 2, provide the name, address, home and work telephone numbers, email address, employer name, address and telephone number of the subject you are filing a complaint against.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 4: In section 3, indicate whether the subject is a engineer, land surveyor or firm with a check mark.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 5: In section 4, indicate what your complaint concerns with a check mark.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 6: In section 5, provide all details requested about your complaint.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 7: In section 6, provide a brief description of your complaint. If necessary, attach additional numbered and signed sheets. 

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 8: In section 7, list supportive documents such as copies of court orders, receipts and canceled checks. 

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 9: In section 8, list the name, address and telephone number of all other known parties with direct interest in this case or who can provide pertinent information.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 10: In section 9, state what you want done to remedy this situation.

Alabama Board Of Licensure For Professional Engineers And Land Surveyors Complaint Form  Step 11: In section 10, indicate whether you have entered or anticipate litigation regarding this matter with a check mark.

INSTRUCTIONS: ALABAMA APPLICATION AS UTILIZATION REVIEW ENTITY (Form WC 50)

The form discussed in this article is used to screen applicants applying for utilization review entity as part of the workers' compensation process. This document can be obtained from the website maintained by the Alabama Department of Labor.

Alabama Application As Utilization Review Entity WC 50 Step 1: Part 1 concerns general information. Enter your agency name on the first blank line.

Alabama Application As Utilization Review Entity WC 50 Step 2: Enter your agency address on the second blank line.

Alabama Application As Utilization Review Entity WC 50 Step 3: Enter your agency telephone number, including the area code, on the third blank line.

Alabama Application As Utilization Review Entity WC 50 Step 4: Enter your agency toll-free telephone number, including the area code, on the fourth blank line.

Alabama Application As Utilization Review Entity WC 50 Step 5: Enter the name of a contact person and their title on the fifth blank line.

Alabama Application As Utilization Review Entity WC 50 Step 6: Enter a contact email address on the sixth blank line.

Alabama Application As Utilization Review Entity WC 50 Step 7: Part 2 concerns certifications already held. Indicate whether you have the certifications listed by checking "Yes" or "No" as applicable. If the answer to either listed, you are not required to complete the remainder of the form.

Alabama Application As Utilization Review Entity WC 50 Step 8: Part 3 concerns the purpose for this application. Part I of this section concerns applications for limited certification as a utilization review entity for performance of approvals only. Complete this section as directed.

Alabama Application As Utilization Review Entity WC 50 Step 9: Part II concerns applications for full certification as a utilization review entity. Complete this section as directed.

Alabama Application As Utilization Review Entity WC 50 Step 10: The fourth page contains a statement of certification. On the first blank line, enter the name of the agency on behalf of which you are filing.

Alabama Application As Utilization Review Entity WC 50 Step 11: On the second blank line, enter the name of the company.

Alabama Application As Utilization Review Entity WC 50 Step 12: Enter your signature, name and title on the last three blank lines. Have the form certified by a notary public.

INSTRUCTIONS: ARIZONA APPLICATION FOR SPECIAL BONUS GAME (Form 71-5411)

In Arizona, a form 71-5411 is used to request permission to conduct a special bonus game when administering bingo games. This document can be obtained from the website of the Arizona Department of Revenue.

Arizona Application For Special Bonus Game 71-5411 Step 1: On line 1, enter your name and license number, if known.

Arizona Application For Special Bonus Game 71-5411 Step 2: On line 2, enter your address.

Arizona Application For Special Bonus Game 71-5411 Step 3: On line 3, enter the days and times of the week during which special bonus games will be played.

Arizona Application For Special Bonus Game 71-5411 Step 4: On line 4, enter the pattern required to accomplish bingo.

Arizona Application For Special Bonus Game 71-5411 Step 5: On line 5, enter the number of calls within which a bingo must be accomplished.

Arizona Application For Special Bonus Game 71-5411 Step 6: On line 6, enter the amount of the designated prize.

Arizona Application For Special Bonus Game 71-5411 Step 7: On line 7, enter the type of card to be used.

Arizona Application For Special Bonus Game 71-5411 Step 8: On line 8, enter the cost of a card to the player.

Arizona Application For Special Bonus Game 71-5411 Step 9: On line 9, enter the game number.

Arizona Application For Special Bonus Game 71-5411 Step 10: On line 10, enter how much of the $12,000 prize amount available in the quarter will be guaranteed, if any.

Arizona Application For Special Bonus Game 71-5411 Step 11: On line 11, describe how the special bonus game program will be conducted and the total prize amount offered per quarter.

Arizona Application For Special Bonus Game 71-5411 Step 12: On the next blank line, enter your name.

Arizona Application For Special Bonus Game 71-5411 Step 13: On the last blank line, enter your signature.

Arizona Application For Special Bonus Game 71-5411 Step 14: Mail the form to the Arizona Department of Revenue, whose website can be obtained from their address. 

Arizona Application For Special Bonus Game 71-5411 Step 15: Approval of your application expires at the end of each licensing period. It must be renewed prior to that time in order to allow the continuance of special bonus games.

INSTRUCTIONS: CONNECTICUT MEDICAL DISCOUNT PLAN (MDP) LICENSE RENEWAL 

To apply for a renewal of a Connecticut medical discount plan (MDP) license, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Medical Discount Plan (MDP) License Renewal Step 1: The first page contains general instructions.

Connecticut Medical Discount Plan (MDP) License Renewal Step 2: On the first blank line of the second page, enter the calendar year for which you are filing.

Connecticut Medical Discount Plan (MDP) License Renewal Step 3: On the second blank line, enter the name of the MDP.

Connecticut Medical Discount Plan (MDP) License Renewal Step 4: On the third blank line, enter all names used to market the MDP plan.

Connecticut Medical Discount Plan (MDP) License Renewal Step 5: On the fourth blank line, enter the MDP connecticut license number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 6: On the fifth blank line, enter the MDP tax identification number or federal employer identification number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 7: On the next three blank lines, enter the business address of the MDP.

Connecticut Medical Discount Plan (MDP) License Renewal Step 8: If your mailing address is different from your business address, enter it on the next two blank lines.

Connecticut Medical Discount Plan (MDP) License Renewal Step 9: On the eleventh blank line, enter the MDP phone number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 10: Indicate with a check mark whether any suspension, sanction or disciplinary action has been taken against the MDP in any state. If yes, explain.

Connecticut Medical Discount Plan (MDP) License Renewal Step 11: Indicate with a check mark whether any suspension, sanction or disciplinary action has been taken against the controlling company or organization in any state. If yes, explain.

Connecticut Medical Discount Plan (MDP) License Renewal Step 12: At the top of the third page, enter the total number of enrollees served by the plan both nationwide and in Connecticut.

Connecticut Medical Discount Plan (MDP) License Renewal Step 13: List all provider networks with which the MDP has contracts or agreements to provide discounted health services to Connecticut enrollees.

Connecticut Medical Discount Plan (MDP) License Renewal Step 14: Complete the rest of the form as instructed.

INSTRUCTIONS: CONNECTICUT AFFIDAVIT OF COMPLAINT STATE ELECTIONS ENFORCEMENT COMMISSION

To file a complaint regarding an election violation in Connecticut, use the affidavit discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 1: Section I concerns the identity of the complainants. Enter their name, address, home, work and cell telephone numbers and email address. You may document up to three complainants in this section.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 2: Section II concerns the identity of the respondents. You may document up to three respondents on the page provided. Enter the name, address, home phone number, work phone number, cell phone number and email address of each respondent. Should you require additional space to document all respondents, attach additional copies of this page. Check the box where indicated and enter the number of additional pages attached.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 3: Section III concerns the violations being alleged. Enter the date or dates of the alleged violations, if known, where indicated.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 4: In the space provided, provide a concise statement of the facts of these alleged violations.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 5: Section IV concerns witnesses to these alleged violations. For each witness, enter their name, address, work phone number, home phone number, cell phone number, and email address.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 6: Section V concerns evidence of these alleged violations. For each evidentiary attachment, enter the title of the document, the number of pages, the author, the date of publication, how you acquired this evidence, and the date of your acquisition. 

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 7: If there is not enough space provided for documentation of all evidentiary attachments, complete additional pages. Check the box where indicated and write how many additional pages are attached. 

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 8: Section VI concerns certification of your statement. The complainant should sign and date the form where indicated in the presence of a notary public, justice of the peace, town clerk or a similarly authorized official. 

INSTRUCTIONS: CONNECTICUT PROPERTY EXECUTION PROCEEDINGS APPLICATION, ORDER, EXECUTION (Form JD-CV-5)

When a Connecticut case has resulted in a judgment against the debtor but full or partial payment has not been made as ordered, the judgment creditor should complete a form JD-CV-5 to request enforcement of the ruling. This document can be found on the website of the Connecticut Judicial Branch.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 1: The application section should be completed by the judgment creditor or their attorney. In the first blank box, enter the address of the court and indicate with a check mark whether it is a geographical area, judicial district or housing session court.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 2: In the second blank box, enter the date of judgment.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 3: In the third blank box, enter the docket number.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 4: In the fourth blank box, enter the name and address of the judgment creditor or creditors making this application.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 5: In the fifth blank box, enter the name and address of the judgment debtor or debtors.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 6: In box 1, enter the amount of judgment.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 7: In box 2, enter the amount of costs and fees.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 8: In box 3, enter the total of the judgment amount, costs and fees.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 9: In box 4, enter the total amount paid, if any.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 10: In box 5, enter the total amount unpaid by subtracting box 4 from box 3.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 11: In box 6, enter the application fee for property execution if not waived by the court. Add boxes 5 and 6 and enter the resulting sum in box 7.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 12: Complete the rest of Section I as directed. Section II will be completed by the assistant clerk of the court.