SOUTH CAROLINA SECRETARY OF STATE EMPLOYMENT AGENCY RENEWAL APPLICATION FOR LICENSE TO OPERATE Filing Instructions The filing fee for this renewal application is $100. This application must be completed in its entirety. If there are any questions not answered, signatures missing or required documents not attached, this form will be returned for correction. Please contact our office with any questions regarding this form at 803-734-0367. This application must be mailed to: South Carolina Secretary of State, Employment Agencies, 1205 Pendleton St., Ste. 525, Columbia, SC 29201 1. Business Contact Information: a. Full Name b. Phone Number c. Email Address 2. Business Entity Information: a. Business Name b. Trade Name or DBA (if applicable) c. Physical Location of Business (Street, City, Zip Code, County) d. Mailing Address of Business (If different from above) e. Phone Number f. Website 3. Entity's Type of Ownership: ____ Sole Proprietor ____ Partnership ____ Corporation, Association, or Society 4. Application Made By (complete the appropriate section): a. Sole Proprietor-- (Application must be made by the owner.) Name Address (Street, City, Zip Code) Prior Business or Occupation of the Applicant Renewal Application for License, Employment Agency, revised October 2013 American LegalNet, Inc. www.FormsWorkFlow.com b. Partnership-- (Application must be made by all of the partners; attach a separate sheet if necessary.) Name Address (Street, City, Zip Code) % Owned Prior Business or Occupation of the Applicant Name Address (Street, City, Zip Code) % Owned Prior Business or Occupation of the Applicant c. Corporation, Association, or Society-- (Application must be made by the president, vice-president, secretary, and treasurer and by a person owning twenty percent or more of the stock.) President Name Address (Street, City, Zip Code) % Owned Prior Business or Occupation of the Applicant VicePresident Name Address (Street, City, Zip Code) % Owned Prior Business or Occupation of the Applicant Secretary Name Address (Street, City, Zip Code) % Owned Prior Business or Occupation of the Applicant Treasurer Name Address (Street, City, Zip Code) % Owned Prior Business or Occupation of the Applicant Stockholder Name Address (Street, City, Zip Code) % Owned Prior Business or Occupation of the Applicant 5. Have any of the applicants listed above previously held or applied, whether granted or denied, for a private personnel placement service license within the United States or its possessions or territories? a. ___ No ___ Yes If yes, was the private personnel placement service license ever denied or revoked? ___ No ___ Yes If yes, please attach an explanation to this application. Renewal Application for License, Employment Agency, revised October 2013 American LegalNet, Inc. www.FormsWorkFlow.com 6. List the person who will actually direct and operate the placement activities: Name Address (Street, City, Zip Code) Prior Business or Occupation of the Applicant 7. The application must be accompanied by a verification of a surety bond of three thousand dollars ($3,000.00) or other security equal to twenty-five thousand dollars ($25,000.00) in a form approved by the Attorney General and deposited with the Secretary of State. (Please attach Surety Bond Verification form.) a. Surety bond issued by: _____________________________________________________ b. Bond number: ______________________________ c. Bond expiration date: _______________________ Please read and acknowledge each of the following statements. I(we) acknowledge that in accordance with the South Carolina Private Personnel Placement Services Act, South Carolina Code of Laws Section 41-25-10 et seq.: 1. If a licensee relocates its offices before filing the annual renewal notice, the licensee shall submit a written notice of the change of address to the Secretary containing a notarized statement that the new location conforms to licensing requirements. 2. Failure to maintain a surety bond of three thousand dollars ($3,000.00) in force or have other security filed with the Secretary of State of twenty-five thousand dollars ($25,000.00) constitutes disqualification for retaining a license. 3. Licenses are issued for two years beginning January 1st through December 31st unless turned in or revoked by the Secretary. Licenses must be renewed biennially and must be postmarked no later than the last day of December. 4. If a licensee ceases to operate or goes out of business, the licensee shall notify the Secretary in writing of the action and return the license to the Secretary of State. 5. If a business is sold to a new owner, the previous owner shall notify the Secretary of State in writing to whom the business is being sold and return the license to the Secretary and state. That business may not operate until the new owner has obtained a new license. 6. Private Personnel Placement Services licenses are nontransferable absolutely and unconditionally. I(we) further acknowledge that: 7. Any person who knowingly violates S.C. Code of Laws Sections 41-25-30, 41-25-40, 41-25-50, 41-25-60, 41-25-70, or 41-25-80 is guilty of a misdemeanor and upon conviction must be fined not more than five hundred dollars ($500.00) or imprisoned for not more than one year, or both, for a first offense. 8. Anyone convicted of violating the above-stated code sections must be denied the right to operate as a private personnel placement service and shall immediately surrender his or her license to the Secretary. 9. Failure to surrender the license shall subject the licensee to a misdemeanor with a fine of not more than five hundred dollars ($500.00) or imprisoned for not more than one year, or both. Each day of noncompliance constitutes a separate offense. Renewal Application for License, Employment Agency, revised October 2013 American LegalNet, Inc. www.FormsWorkFlow.com Each applicant listed in questions #4 a-c must complete this certification: I, the applicant, certify under the penalty of perjury, that I have read and understand each of the items above. Furthermore, I certify that the information furnished in this application and all attached supplementary information is true and correct to the best of my knowledge, information and belief. Applicant: ____________________________________________ Signature: ____________________________________________ Applicant: ____________________________________________ Signature: ____________________________________________ Title: _