Pharmacy Discount Cards - Montana Commissioner of Securities and Insurance

nathaniel-yeo-gUZo-UA0VGQ-unsplash - Montana Commissioner of Securities and Insurance

PHARMACY DISCOUNT CARD FORM

Pharmacy Discount Card Registration Form

Company(Required)

Compliance Contact Last Name(Required)

Compliance Contact First Name(Required)

Compliance Contact Phone Number(Required)

Compliance Contact Address(Required)

Street Address Address Line 2 City State ZIP Code

Compliance Contract Email Address(Required)

Verification(Required)

Your organization verifies compliance with the Pharmacy Discount Card supplier requirements set forth in Montana Code Annotated § 33-38-108

Signature(Required)

I certify that I am authorized to complete this certification on behalf of the Pharmacy Discount Card Supplier listed above and that the information contained in this registration is true, accurate and complete to the best of my knowledge.

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