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SEEC Form 4 Exploratory Committee Registration

SEEC Form 4 Exploratory Committee Registration

 

INSTRUCTIONS: CONNECTICUT EXPLORATORY COMMITTEE REGISTRATION (SEEC Form 4)

 

 

To register a Connecticut exploratory committee, use a SEEC form 4. This document can be obtained from the website of the government of Connecticut.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 1: Enter the election date in box 1. 

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 2: Check one box in boxes 2a through 2d to indicate the subtype of the exploratory committee office being considered.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 3: Enter the candidate's name in box 3.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 4: Enter the candidate's residential address in box 4 and their mailing address, if different, in box 5.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 5: Enter the candidate's telephone number in box 6 and their email address in box 7.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 6: In box 8, indicate the candidate's political affiliation.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 7: Enter the name of the committee in box 9.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 8: Enter the committee address in box 10.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 9:  Enter the committee telephone number in box 11 and their email address in box 12.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 10: In box 13, enter the name of the treasurer.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 11: In box 14, enter the treasurer's residential address. If their mailing address is different, enter it in box 15.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 12: Enter the treasurer's telephone number in box 16 and their email address in box 17.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 13: Enter the deputy treasurer's name in box 18, their residential address in box 19, their mailing address (if different) in box 20, their telephone number in box 21 and their email address in box 22.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 14: In box 23, enter the depository institution name.

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 15: Enter the depository institution address in box 24. 

 

Connecticut Exploratory Committee Registration SEEC Form 4 Step 16: The candidate should sign and date the form in box 25.

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SEEC Form 5 Exploratory Committee Notice of Intent to Dissolve

SEEC Form 5 Exploratory Committee Notice of Intent to Dissolve

 

INSTRUCTIONS: CONNECTICUT EXPLORATORY COMMITTEE NOTICE OF INTENT TO DISSOLVE (SEEC Form 5)

 

 

When a Connecticut exploratory committee decides to dissolve, they should file a SEEC form 5. This document can be obtained from the website of the government of Connecticut.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 1: In box 1, enter the election date.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 2: In box 2, enter the prefix, first name, middle initial, last name and suffix (if applicable) of the candidate.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 3: In box 3, give the residential street address, city, state and zip code of the candidate.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 4: If the candidate's mailing address address from the one in box 3, enter it in box 4.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 5: In box 5, enter the telephone number of the candidate.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 6: In box 6, enter the email address of the candidate.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 7: In box 7, indicate with a check mark whether the candidate is a Republican, a Democrat or other. If the latter, specify.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 8: In box 8, enter the name of the committee.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 9: In box 9, enter the street address, city, state and zip code of the committee.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 10: In box 10, enter the committee email address.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 11: In box 11, enter the committee web site address.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 12: Check box 12a if the candidate intends to continue seeking nomination or election. Enter the office sought, the district number, and the name of the candidate committee.

 

Connecticut Exploratory Committee Notice Of Intent To Dissolve SEEC Form 5 Step 13: Check box 12b if you will not seek nomination or election.

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Pharmacy Benefits Manager (PBM) Initial Application for a Certificate of Registration

Pharmacy Benefits Manager (PBM) Initial Application for a Certificate of Registration

 

INSTRUCTIONS: CONNECTICUT PHARMACY BENEFITS MANAGER (PBM) CERTIFICATE OF REGISTRATION (INITIAL)

 

 

To apply for an initial certificate of registration as a pharmacy benefits manager (PBM) in Connecticut, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 1: The first page contains general instructions.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 2: On the first four blank lines of the second page, enter your tax identification number or federal employer identification number, your business address, your mailing address (if different) and your phone number.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 3: The next section concerns contact information to be used in future correspondence. Enter the name of your contact person, their title, a mailing address, phone and fax numbers, and an email address.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 4: Enter the name and a description of the controlling company or organization.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 5: Enter the business address and, if different, the mailing address of the controlling company or organization.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 6: The next question requires you to indicate whether any suspension, sanction or disciplinary action has been taken against the PBM in any state during the last ten years. If yes, provide an explanation.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 7: The first question on the third page requires you to indicate whether any suspension, sanction or disciplinary action has been taken against the controlling company or organization during the last ten years. If yes, provide an explanation.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 8: Describe the PBM service area.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 9: Enter the number of total enrollees served by the PBM both nationwide and in Connecticut.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 10: List all entities on whose behalf the PBM has contracts or agreements to provide pharmacy benefit services to Connecticut enrollees.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 11: Complete the rest of the form as instructed. 

 

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Pharmacy Benefits Manager (PBM) Renewal Application for a Certificate of Registration

Pharmacy Benefits Manager (PBM) Renewal Application for a Certificate of Registration

INSTRUCTIONS: CONNECTICUT PHARMACY BENEFITS MANAGER (PBM) CERTIFICATE OF REGISTRATION (RENEWAL)

 

 

To apply for a renewal of your registration certificate as a Connecticut pharmacy benefits manager (PBM), use the document discussed in this article. This application can be obtained from the website of the government of Connecticut.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 1: The first page contains general instructions for completion of this form.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 2: On the first five blank lines of the second page, enter the name of the PBM, its registration number, its tax identification number or federal employer identification number, its business address, its mailing address (if different) and its phone number.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 3: The question below asks if any suspension, sanction or disciplinary action has been taken against the PBM in any state. If yes, provide an explanation.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 4: The question below asks if any suspension, sanction or disciplinary action has been taken against the controlling company or organization in any state. If yes, provide an explanation.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 5: Describe the PBM service area.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 6: Enter the total number of enrollees served by the PBM both nationwide and solely in Connecticut.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 7: At the top of the third page, list all entities on whose behalf the PBM has contracts or agreements to provide benefit services to Connecticut enrollees. 

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 8: The remainder of the third page is a checklist of required attachments to be submitted with this form.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 9: The fourth page concerns your financial security requirement. Calculate your surety bond as instructed.

 

Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 10: The fifth page is a certificate of accuracy which must be completed by the CEO. Enter their name on the first blank line, their location on the second blank line, their signature on the third blank line, and the date on the fourth blank line.

 

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