Office of the South Carolina Secretary of State Designation of Registered Agent for Discount Drug Card Sellers TYPE OR PRINT CLEARLY WITH BLACK INK Pursuant to the provisions of Section 37-17-10 of the 1976 South Carolina Code of Laws, as amended, the applicant delivers to the Secretary of State the following: 1. Name and address of authorized seller of discount drug card(s): __________________________________________________________ __________________________________________________________ __________________________________________________________ 2. State and date of incorporation of seller if seller is a corporation: __________________________________________________________ 3. Name and physical address of designated South Carolina agent for service: __________________________________________________________ __________________________________________________________ __________________________________________________________ 4. South Carolina mailing address of designated agent: __________________________________________________________ __________________________________________________________ __________________________________________________________ Signature of designated agent: ______________________________________ Filing instructions: 1. 2. 3. Two copies of this form, original and either a duplicate original or a conformed copy, must be filed. Must be signed by the designated agent. $10.00 filing fee made payable to the Secretary of State's Office. Secretary of State 1205 Pendleton Street Suite 525 Columbia, SC 29201 Return to: American LegalNet, Inc. www.FormsWorkFlow.com