Discount Medical Plan Organization Application Name of Applicant: DBA (if applicable): Home Office Address: Street or PO Box City State Zip Code Mailing Address: Street or PO Box City Zip Code Contact Person: Phone Number: Fax Number: E-mail Address: Compliance Officer: Address: Phone Number: Fax Number: E-mail Address: Type of Business Organization: Corporation Limited Liability Company Partnership Other (Identify/Explain): State of Domicile: Formation Date: FEIN Number: mm/dd/yyyy List all states which the applicant is currently registered as a discount medical plan organization. List all states which a discount medical plan organization application has been refused or denied. List Names and Addresses of all Members, or Officers, or Owners of the Applicant: Full Name Title Address % Ownership
Discount Medical Plan Organization Application Name of Applicant: DBA (if applicable): Home Office Address: Street or PO Box City State Zip Code Mailing Address: Street or PO Box City Zip Code Contact Person: Phone Number: Fax Number: E-mail Address: Compliance Officer: Address: Phone Number: Fax Number: E-mail Address: Type of Business Organization: Corporation Limited Liability Company Partnership Other (Identify/Explain): State of Domicile: Formation Date: FEIN Number: mm/dd/yyyy List all states which the applicant is currently registered as a discount medical plan organization. List all states which a discount medical plan organization application has been refused or denied. List Names and Addresses of all Members, or Officers, or Owners of the Applicant: Full Name Title Address % Ownership
DMPO%20Application%20(DMP-1).docx