INSTRUCTIONS: CONNECTICUT REQUEST FOR ADMINISTRATIVE REVIEW (Form B-360)

To request an administrative review of an application filed with the Connecticut Department of Motor Vehicles, file a form B-360. This document can be obtained from the website of the government of the state of Connecticut.

Connecticut Request For Administrative Review B-360 Step 1: Check the first box if requesting a review of a motor vehicle registration application.

Connecticut Request For Administrative Review B-360 Step 2: Check the second box if requesting a review of an application for an operator's license.

Connecticut Request For Administrative Review B-360 Step 3: Check the third box if requesting a review of an application for a CDL operators license.

Connecticut Request For Administrative Review B-360 Step 4: Check the fourth box if requesting a review of another type of application and specify.

Connecticut Request For Administrative Review B-360 Step 5: On the first blank line, enter your full name. Print or type all responses in this section of the form.

Connecticut Request For Administrative Review B-360 Step 6: On the second blank line, enter your street address, city, state and zip code.

Connecticut Request For Administrative Review B-360 Step 7: On the third blank line, enter your telephone number, including the area code.

Connecticut Request For Administrative Review B-360 Step 8: On the fourth blank line, enter your hours of contact at this telephone number.

Connecticut Request For Administrative Review B-360 Step 9: On the fifth blank line, enter your email address.

Connecticut Request For Administrative Review B-360 Step 10: On the sixth blank line, state the reason for your request.

Connecticut Request For Administrative Review B-360 Step 11: In the space provided, provide an explanation of the justification for your request.

Connecticut Request For Administrative Review B-360 Step 12: In the space provided, list the support documents submitted.

Connecticut Request For Administrative Review B-360 Step 13: On the next blank line, enter the date.

Connecticut Request For Administrative Review B-360 Step 14: On the next blank line, enter your signature.

Connecticut Request For Administrative Review B-360 Step 15: Mail the completed document, along with supporting documentation, to the address given at the bottom of the page. Alternately, you may submit these papers via fax to the number also given at the bottom of the page.

INSTRUCTIONS: ALABAMA OFFICE-BASED SURGERY ADVERSE EVENT REPORT FORM

Following an office-based surgery in Alabama which results in an adverse event, the report form discussed in this article should be filed. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Office-Based Surgery Adverse Event Report Form Step 1: Enter your name on the first blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 2: Enter your Alabama license number on the second blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 3: Enter your street address, city, state and zip code on the third blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 4: Enter your specialty as a physician on the fourth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 5: Enter the date of surgery on the fifth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 6: Enter the type of surgery on the sixth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 7: Enter the type of anesthesia used on the seventh blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 8: Enter the name and title of the person administering anesthesia on the eight blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 9: Enter the date of the adverse event on the ninth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 10: Enter the type of adverse event on the tenth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 11: Indicate whether the patient was hospitalized with a check mark.

Alabama Office-Based Surgery Adverse Event Report Form Step 12: Indicate whether the patient experienced a full recovery, disability, death or whether the outcome is pending with a check mark.

Alabama Office-Based Surgery Adverse Event Report Form Step 13: In the blank space provided, enter a brief narrative description of what occurred during this event and any changes in office protocol that have been implemented to prevent a repetition of this event. Attach additional sheets if necessary.

Alabama Office-Based Surgery Adverse Event Report Form Step 14: Enter your signature on the next blank line and the date on the last blank line. File the form by emailing it to the address given at the bottom of the page or mailing it to the address given at the top of the page.

INSTRUCTIONS: APPLICATION FOR REPLACEMENT/WALL CERTIFICATE ALABAMA MEDICAL LICENSE

To apply for a new or replacement wall certificate documenting your Alabama medical license, file the form discussed in this article. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners & Medical Licensure Commission of Alabama.

Application For Replacement/Wall Certificate Alabama Medical License Step 1: Enter your license number on the first blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 2: Enter your name on the second blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 3: Enter your mailing street address on the third blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 4: Enter your city on the fourth blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 5: Enter your state on the fifth blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 6: Enter your zip code on the sixth blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 7: Check the first statement if your license was lost.

Application For Replacement/Wall Certificate Alabama Medical License Step 8: Check the second statement if your license was destroyed. 

Application For Replacement/Wall Certificate Alabama Medical License Step 9: Regardless of whether your license was lost or destroyed, a notarized affidavit documenting how and when your license was lost or destroyed must be attached.

Application For Replacement/Wall Certificate Alabama Medical License Step 10: Check the third statement if you require a replacement wall certificate due to a name change.

Application For Replacement/Wall Certificate Alabama Medical License Step 11: If requesting a replacement wall certificate due to a name change, give the reason for this change on the next blank line. A copy of the legal document verifying the name change must be submitted with your application.

Application For Replacement/Wall Certificate Alabama Medical License Step 12: Enter your signature on the next blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 13: Enter the date on the next blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 14: Submit the application to the address given at the bottom of the page, along with your affidavit. Additionally, you must enclose payment for the fee for this service, which is $25.

INSTRUCTIONS: ALABAMA REFUND REQUEST (Form PEEHIP RR)

In Alabama, a request for a refund from the state administered public education employees' health insurance plan is submitted using a form PEEHIP RR. This document can be obtained from the website of the retirement systems of Alabama.

Alabama Refund Request PEEHIP RR Step 1: Enter the employee's name on the first blank line.

Alabama Refund Request PEEHIP RR Step 2: Enter the employee's Social Security number on the third blank line.

Alabama Refund Request PEEHIP RR Step 3: Enter the employee's system on the third blank line.

Alabama Refund Request PEEHIP RR Step 4: On the fourth blank line, enter the amount of the insurance premium you wish to be refunded to the member.

Alabama Refund Request PEEHIP RR Step 5: On the fifth blank line, enter the amount of the insurance premium you wish to be refunded to the system.

Alabama Refund Request PEEHIP RR Step 6: On the sixth blank line, enter the month or months to which the refund applies.

Alabama Refund Request PEEHIP RR Step 7: On the seventh blank line, detail your coverages.

Alabama Refund Request PEEHIP RR Step 8: On the eighth blank line, provide the reason for your request.

Alabama Refund Request PEEHIP RR Step 9: On the ninth blank line, enter the name of the member to whom the refund should be mailed.

Alabama Refund Request PEEHIP RR Step 10: On the tenth blank line, enter the member's street address or P.O. box number.

Alabama Refund Request PEEHIP RR Step 11: On the eleventh blank line, enter the member's city, state and zip code.

Alabama Refund Request PEEHIP RR Step 12: On the twelfth blank line, enter the system name.

Alabama Refund Request PEEHIP RR Step 13: On the thirteenth blank line, enter the system street address or P.O. box number.

Alabama Refund Request PEEHIP RR Step 14: On the fourteenth blank line, enter the system city, state and zip code.

Alabama Refund Request PEEHIP RR Step 15: On the fifteenth blank line, enter the name of the school system.

Alabama Refund Request PEEHIP RR Step 16: On the sixteenth blank line, enter the date.

Alabama Refund Request PEEHIP RR Step 17: The applicable official should enter their signature on the last blank line.

INSTRUCTIONS: CONNECTICUT MEDICAL DISCOUNT PLAN (MDP) LICENSE APPLICATION

To apply for a medical discount plan (MDP) license in Connecticut, 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 Application Step 1: The first page contains general instructions for filing this application.

Connecticut Medical Discount Plan (MDP) License Application Step 2: Enter the calendar year for which you are filing on the first blank line of the second page.

Connecticut Medical Discount Plan (MDP) License Application Step 3: Enter the name of the MDP on the second blank line.

Connecticut Medical Discount Plan (MDP) License Application Step 4: Enter the email address of the MDP on the third blank line.

Connecticut Medical Discount Plan (MDP) License Application Step 5: List all names used to market your MDP card on the fourth blank line.

Connecticut Medical Discount Plan (MDP) License Application Step 6: Enter your MDP tax identification number or federal employer identification number on the fifth blank line.

Connecticut Medical Discount Plan (MDP) License Application Step 7: Enter your MDP business address on the next three blank lines.

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

Connecticut Medical Discount Plan (MDP) License Application Step 9: Enter your MDP phone number on the next blank line.

Connecticut Medical Discount Plan (MDP) License Application Step 10: The next section concerns contact information to be used for all future related correspondence. On the first two blank lines, enter the name and title of a contact person.

Connecticut Medical Discount Plan (MDP) License Application Step 11: Enter the contact person's mailing address on the next two blank lines.

Connecticut Medical Discount Plan (MDP) License Application Step 12: Enter the contact person's phone number and fax number on the next two blank lines.

Connecticut Medical Discount Plan (MDP) License Application Step 13: Enter the name and a description of your controlling company and organization.

Connecticut Medical Discount Plan (MDP) License Application Step 14: Enter a contact name for the controlling company or organization.

Connecticut Medical Discount Plan (MDP) License Application Step 15: Complete the remainder of the application as instructed.

INSTRUCTIONS: CONNECTICUT CITIZENS' ELECTION PROGRAM – DECLARATION OF JOINT CAMPAIGN BY PARTICIPATING CANDIDATES FOR GOVERNOR AND LT. GOVERNOR (SEEC Form CEP 18)

Two people running a joint campaign for governor and lieutenant governor in Connecticut use an  SEEC form CEP 18 to document this. This form can be obtained from the website of the government of Connecticut.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 1: In box 1, enter the election date.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 2: In box 2, enter the name of the governor candidate's candidate committee.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 3: In box 3, enter the name of the candidate for governor.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 4: In box 4, enter the name of the governor candidate committee's treasurer.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 5: In box 5, enter the name of the governor candidate committee's deputy treasurer, if applicable.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 6: In box 6, enter the name of the lieutenant governor candidate's candidate committee.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 7: In box 7, enter the name of the candidate for lieutenant governor.

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 8: In box 8, enter the name of the lieutenant governor candidate committee's treasurer. 

Connecticut Citizens' Election Program – Declaration Of Joint Campaign By Participating Candidates For Governor And Lt. Governor SEEC Form CEP 18 Step 9: In box 9, enter the name of the lieutenant governor candidate committee's deputy treasurer, if applicable. Both candidates should sign and date the second page.

INSTRUCTIONS: CONNECTICUT EXEMPTION AND MODIFICATION CLAIM FORM, WAGE EXECUTION (Form JD-CV-3a)

In Connecticut debt cases, a form JD-CV-3a is sent to the debtor's employer as part of the wage garnishing process. This document can be obtained from the website of the Connecticut Judicial Branch.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 1: In the blank section at the top of the first page, enter the name and address of the judgment debtor.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 2: Section I must be completed by the judgment creditor. In the first blank box, indicate with a check mark whether this case is being processed by a judicial district court, a housing session court or a geographical area court. If the latter, give its number.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 3: In the second blank box, enter the name and address of the court.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 4: In the third blank box, enter the name of the case.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 5: In the fourth blank box, enter the case docket number.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 6: In the fifth blank box, enter the name of the judgment debtor.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 7: Section II should be completed by the proper officer. In the first blank box, they should enter their name.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 8: In the second blank box, they should enter the date of service of wage execution upon the employer.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 9: Section III must be completed by the employer. In the first blank box, enter your name and address.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 10: In the second blank box, enter the telephone number of your payroll department.

Connecticut Exemption And Modification Claim Form, Wage Execution JD-CV-3a Step 11: In the next three blank boxes, enter the date of mailing or delivery of the judgment order, the total amount of wage execution and the amount to be taken out from weekly earnings. The debtor may apply for an exemption or modification using sections V and VI.