State of South Carolina Office of the Secretary of State Mark Hammond Public Charities Division P.O.Box 11350 Columbia, SC 29211 803-734-1790 APPLICATION FOR LICENSE TO OPERATE AN EMPLOYMENT AGENCY To the Secretary of State, I (we) the undersigned __________________________________________________________________ (Person, Partnership or Corporation) of _______________________________________________________________________________________________________________ (Street Address) (City) (State) (zip) do hereby make application for license to operate an employment agency under Act R228 of the General Assembly of the State of South Carolina. License fee in the amount of one hundred ($100.00) dollars and application fee in the amount of two hundred ($200.00) dollars for a total of three hundred ($300.00) dollars and bond in the penal sum of three thousand ($3000.00) dollars are submitted herewith. 1. Name and address of agency for which this application is made: Corporate or Business Name:___________________________________________________________________________ Contact Name:______________________________________________________ Title:_____________________________ Street Address: __________________________________________ Suite:________________________________________ City:______________________________________ State:__________________________ Zip Code:___________________ Phone Number:_________________________________ Fax Number:__________________________________________ Email Address: _________________________________ Website: _____________________________________________ Trade Name(s):_________________________________________________________________________________________ (A) If Corporation, list name, address, and social security number of: President:_______________________________________________________________________SSN:_______________ Vice President:__________________________________________________________________SSN:_______________ Secretary:_______________________________________________________________________SSN:_______________ Treasurer:_______________________________________________________________________SSN:_______________ (B) If Partnership, list name, address, and social security number of each partner: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 2. Business or occupation engaged in by applicant previously: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ (A) Has any officer or partner previously held or applied for a license within the United States, its possessions,or territories? Yes □ (B) If so, was license granted or denied? No □ Granted □ Denied □ 1 American LegalNet, Inc. www.USCourtForms.com 3. Name, address, and phone number of the person at this agency location who will operate and direct the placement activities: ____________________________________________________________________________________________________ Name and address of the last employer of person listed above: _________________________________________________ ______________________________________________________________________________________________________________ 4. Has applicant ever operated or been associated with any private employment agency? Yes □ No □ If yes, give name of agency(s) and position(s) held: _____________________________________________________________ 5. Has applicant ever been bonded? Yes □ No □ If yes, list in which state(s): ____________________________________ (A) Applicant’s name as listed on bond:____________________________________________________________________ (B) Name of surety company:____________________________________________ Date:___________________________ (C) Has applicant had bond canceled or application rejected? Yes □ No □ If yes, state reason:____________________________________________________________________________________ 6. Names and addresses of places of employment during last three years. If partnership, give employment of each partner. give employment of each officer. 1) If corporation, Name of partner or officer of corporation:_______________________________________________________________ Name and address of employer:________________________________________________________________________ Dates of employment: From:__________________ To:____________________ Last position held:______________________________ Reason for leaving:____________________________________ 2) Name of partner or officer of corporation:_______________________________________________________________ Name and address of employer:________________________________________________________________________ Dates of employment: From:__________________ To:____________________ Last position held:______________________________ Reason for leaving:____________________________________ 3) Name of partner or officer of corporation:_______________________________________________________________ Name and address of employer:________________________________________________________________________ Dates of employment - From:__________________ To:____________________ Last position held:______________________________ Reason for leaving:____________________________________ 4) Name of partner or officer of corporation:_______________________________________________________________ Name and address of employer:________________________________________________________________________ Dates of employment: From:__________________ To:____________________ Last position held:______________________________ Reason for leaving:____________________________________ 7. List the names and addresses of each person who it is proposed will own twenty percent (20%) or more of the Owners Equity of the agency:___________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 8. Surety Bond Information – Bond Number:_____________________________ Expiration Date:________________________ 2 American LegalNet, Inc. www.USCourtForms.com Issued by:_____________________________________________________________________________________________________ Issued for:____________________________________________________________________________________________________ (Agency) (Owner) Personally appeared before me the undersigned who, being duly sworn, deposes and says that the information submitted in the foregoing application is true and correct to the best of their knowledge, and there is no other information known by the undersigned which would influence in any manner the issuance of the license. 1) Applicant:____________________________________ Date of Birth:___________________________________ Signature:_________________________________________ Date:___________________ Resident of:_____________________________________ Phone Number:_________________________________ 2) Applicant:____________________________________ Date of Birth:___________________________________ Signature:_________________________________________ Date:___________________ Resident of:_____________________________________ Phone Number:_________________________________ 3) Applicant:____________________________________ Date of Birth:___________________________________ Signature:_________________________________________ Date:___________________ Resident of:_____________________________________ Phone Number:_________________________________ Subscribed and sworn before me this ___ day of ___________20___. ________________________________________________________________ (Notary Public) My Commission expires:________________________________________ If Proprietorship, proprietor must sign; if Partnership, each partner must sign; if Corporation, each officer must sign. 3 American LegalNet, Inc. www.USCourtForms.com STATE OF SOUTH CAROLINA BOND NO. ________________ KNOW ALL MEN BY THESE PRESENTS, THAT WE _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ doing business as _____________________________________________________________________________________ an employment agency of _________________________________________________________________as principal, and __________________________________________ of ___________________________________________ as surety, are held firmly bound to the people of the State of South Carolina in the penal sum of $3,000.00, lawful money of the United States of America, to be paid to the people of the State of South Carolina; for which payment we bind ourselves, our heirs, executors, administrators, successors, and assigns jointly and severally, firmly by these presents. The condition of this obligation is that if the above bounden principal complies with the Provision of Act 107 of 1981 of the State of South Carolina and pays all sums due any individual or group of individuals when such principal or his representative or agent has received sums, and pays all damage occasioned to any person by reason of misstatement, misrepresentation, fraud deceit, or any unlawful acts or omissions of the principle mentioned above, or of his agents or employees while acting within the scope of their employment, then this obligation is to be void, otherwise it is to remain in full force and effect. This bond shall be deemed continuous in form and shall remain in full force and effect throughout all succeeding license periods unless terminated or cancelled in the manner hereinafter provided. The State of South Carolina, acting through the Secretary of State, reserves the right, at any time, to terminate this bond (except as to any liability already incurred or accrued) by a written notice of such termination to the surety, and thereupon this bond shall terminate and be of no more force or effect, except as to any liability already incurred or accrued as to which it shall remain in full force and effect. The surety reserves the right to terminate this bond except as to any liability already incurred or accrued and may do so upon giving the said principal and the Secretary of State of the State of South Carolina thirty days written notice to that effect and thirty days after the receipt by the Secretary of State of such notice, its liability under this bond, except as to any liabilities or indebtedness already incurred or accrued, shall cease, and said bond shall thereupon terminate and be of no more force or effect, except as to any liabilities or indebtedness already incurred or accrued thereunder. In witness whereof, the said principal and surety have hereunto set their hands and seals this_________________________________ day of ______________________________________, ___________________. Witnesses: (as to principals) ______________________________________ (Seal) ___________________________________________ ______________________________________ (Seal) ___________________________________________ ______________________________________ (Seal) ______________________________________ (Seal) Witnesses: (as to Surety) ______________________________________ (Seal) ___________________________________________ ______________________________________ (Seal) ___________________________________________ ______________________________________ (Seal) American LegalNet, Inc. www.USCourtForms.com CERTIFICATE OF ATTORNEY In RE:_____________________________________ Date:_____________________ I, _____________________________________, an attorney duly licensed by the South Carolina bar, hereby certify that the employment agency to whose application for license this certificate is attached, has complied with the requirements of S.C. Code Ann. §§ 41-25-10, et. seq., relating to the organization of employment agencies and, in my opinion, the agency is organized for a lawful purpose. __________________________________________ (Signature) Name:_________________________________ Address:_______________________________ ________________________________________ American LegalNet, Inc. www.USCourtForms.com REQUIREMENTS FOR NEWSPAPER ADVERTISEMENT OF APPLICATION FOR LICENSE A NOTICE CONTAINING THE FOLLOWING INFORMATION MUST BE PLACED IN THE NEWSPAPER OF THE GREATEST CIRCULATION IN THE COUNTY OF THE APPLICANT’S LOCATION AND MUST OCCUR ON AT LEAST ONE OCCASION PRIOR TO FILING FOR A LICENSE. ATTACH A COPY OF THE PRINTED NOTICE TO A SIGNED VERIFICATION FROM THE NEWSPAPER THAT STATES WHEN THE AD WAS RUN. NOTICE Please take note that ________________________________ has applied to the Secretary of State’s Office for a license to operate a Private Personnel Placement Service in the name of _________________________________________________________ at the following location: ________________________________________. The said agency will be operated by ___________________________________________. American LegalNet, Inc. www.USCourtForms.com