Type of Applicant. Select the item that best characterizes your organization from the menu in the first drop down box. Additional choices are optional.
Type of Applicant. (see explanatory note) Tick to indicate which case(s) applies to the applicant enterprise: ⃝ Autonomous enterprise In this case the data filled in the box below result from the accounts of the applicant enterprise only. Fill in the declaration only, without annex. ⃝ Partner enterprise Fill in and attach the annex (and any additional ⃝ Linked enterprise sheets), then complete the declaration by copying the results of the calculations into the box below. *In order for an applicant to be considered a Freelancer, they must not exert dominant influence in another enterprise, nor have a holding of 25% or more in another enterprise. Data used to determine the category of enterprise Calculated according to Article 6 of the Annex to the Commission Recommendation 2003/361/EC on the SME definition Reference period (*) Headcount (AWU) Annual turnover (**) Balance sheet total (**)
Type of Applicant. (Required) Select up to three applicant type(s) in accordance with agency instructions. A. State Government B. County Government C. City or Township Government D. Special District Government E. Regional Organization F. U.S. Territory or Possession G. Independent School District H. Public/State Controlled Institution of Higher Education I. Indian/Native American Tribal Government (Federally Recognized) J. Indian/Native American Tribal Government (Other than Federally Recognized) K. Indian/Native American Tribally Designated Organization L. Public/Indian Housing M. Nonprofit N. Private Institution of Higher Education O. Individual P. For-Profit Organization (Other than Small Business) Q. Small Business R. Hispanic-serving Institution S. Historically Black Colleges and Universities (HBCUs) T. Tribally Controlled Colleges and Universities (TCCUs) U. Alaska Native and Native Hawaiian Serving Institutions V. Non-US Entity W. Other (specify)
Type of Applicant. Qualification: • Applicant currently operates as a Medicare managed care organization under a Part C or under a reasonable cost reimbursement contract with CMS. Application Requirements: — • Identify the legal entity (same as Applicant) that would enter into agreement with CMS for approval of its prescription drug discount card program. • Identify all entities with which the Applicant is under contract or other legal arrangement to meet all the card program qualifications. Identify the responsibility of these entities in meeting the qualifications.
Type of Applicant. (Required) Select up to three applicant type(s) in accordance with agency instructions.
