Form Pme 01 PDF Details

The purpose of the PME 01 form is to establish the City's contracting process and procedures. Contractors must complete and submit this form in order to be considered for a contract with the City. The form includes information about the contractor's company, qualifications, experience, and contact information. Submission of the PME 01 form is also required for subcontractors working on a City contract. Completing and submitting this form is an essential step in doing business with the City.

QuestionAnswer
Form NameForm Pme 01
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names non legend drug permit ct form

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PME-01, Rev 09/ 09

STATE OF CONNECTICUT

DEPA RTM ENT OF CONSUM ER PROTECTION

DRUG CONTROL DIVISION

Telephone: (860) 713-6065

Email: drug.control@ct.gov

WebSite: www.ct.gov/dcp

NON-LEGEND DRUG PERMIT APPLICATION

INSTRUCTIONS:

For Official Use Only

All spaces must be completed - please print or type. This application must be accompanied by a check or money order in the amount of $140.00, made payable to: “Treasurer, State of CT.” Application fees are non-refundable.

èReturn your completed application and fee to:

Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106

Name of Business (d/ b/ a)

 

 

 

 

 

FEIN Number:

 

 

 

 

 

 

 

 

Street Address

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

Name of Manager:

 

Type of Business:

Telephone Number :

 

 

 

 

 

Has the Premise had a Previous Non -Legend Drug Permit?

 

Name of Previous Businsess & Permit Number:

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Name of Parent Company (Corporation, Partnership, LLC, etc.)

 

 

 

 

 

 

 

 

 

M ailing A ddress (If different than above)

 

 

 

 

Street Address

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

The applicant understands that in accordance with Section 43(d) of Public Act 95-264 the holder of the Non Legend Drug Permit shall notify the Department of Consumer Protection of any change of ownership, name or location of the permit premises within five (5) days of the change. Failure to do so will result in a $10.00 late fee. Any time the business changes ownership, name or location it shall be cause for re- application.

Non-Legend Drug Permits Are Not Transferable

*Applicant must return the old permit upon changes in ownership, name or location.

I have read the above statement and understand fully my responsibility as holder of a Non Legend Drug Permit.

_______________________________________________________________

_______________________________

SIGNATURE OF APPLICANT

DATE

 

 

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