Business Entity Name: FEIN:  
Address:   City:  
State:   Zip:   Email:  

Questions:

1. Please provide the Name, Address, Official Position, and Professional Qualification of each individual who is responsible for the conduct of the affairs of the PBM, including all members of the board of directors, board of trustees, executive committee, the principal officers in case of a corporation, the partners or members in the case of the partnership or associations.

2. Please provide the name and address of the agent for service of process in the state of Kansas.

Name: Official Position:  
Address:  
Email Address:    Phone Number:  

3. Please provide the name, address, phone number, email address, and official position of the employee who will serve as the primary contact for the Department..

Name: Official Position:  
Address:  
Email Address:    Phone Number: