Form Hcc 90-01 - Health Care Card Suppliers Application Form Of Annual Notice Page 2

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Reset
kansas secretary of state
HCC
Health Care Card Suppliers
Application of Annual Notice
90-01
Please complete the form, print, sign and mail to the
Kansas Secretary of State with the filing fee. Selecting
'Print' will print the form and 'Reset' will clear the entire
form.
Kansas Office of the Secretary of State:
Memorial Hall, 1st Floor
(785) 296-4564
120 S.W. 10th Avenue
kssos@sos.ks.gov
Topeka, KS 66612-1594
THIS SPACE FOR OFFICE USE ONLY.
1.
Name of card supplier
Name
2.
Name of the resident
agent and address of
the registered office
Street Address
in Kansas
Must be a street, rural route,
or highway. A P.O. box is
City
State
Zip
unacceptable
KS
Name
3.
Mailing address
Address will be used to
send official mail from the
Address
Secretary of State’s office
City
State
Zip
Country
4.
I declare under penalty of perjury persuant to the laws of the state of Kansas that the foregoing is true and
correct, and I have remitted the required fee.
Signature of Individual Authorized by Card Supplier
Month
Day
Year
X
Name of Signer (Printed or typed)
Phone number
1 / 1
Please review to ensure completion.
K.S.A. 50-1,101
Rev
. 2/2/16 tc

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