STATE OF SOUTH CAROLINA SECRETARY OF STATE HIGH GROWTH SMALL BUSINESS JOB CREATION ACT APPLICATION FOR REGISTRATION AS QUALIFIED BUSINESS TYPE OR PRINT CLEARLY IN BLACK INK. Pursuant to Section 11-44-60 of the 1976 South Carolina Code of Laws, as amended, the undersigned applicant hereby submits the following information to the Secretary of State for the purpose of registering as a "qualified business" under the High Growth Small Business Job Creation Act of 2013: 1. 2. Initial Application Renewal Application Name of business: Type of business: Corporation General Partnership Other: Limited Liability Company Limited Partnership 3. 4. Date business was incorporated, organized, or formed: Address of business: 5. The location of the headquarters of the business is: Street Address City County State Zip Code 6. Description of the type of business in which the business is engaged: Manufacturing Processing Warehousing Wholesaling 7. Software Development Information Technology Services Research and development Other: Ambulatory Health Care Services Hospitals Nursing and Residential Care Facilities Does the business substantially engage in one or more of the following activities: retail sales; real estate or construction; professional services; gambling; natural resource extraction; financial brokerage, investment activities, or insurance; or entertainment, amusement, recreation, or athletic or fitness activity for which an admission or fee is charged? Yes No Form Revised February 2016 American LegalNet, Inc. www.FormsWorkFlow.com 8. Has the business had a gross income of more than two million dollars ($2,000,000.00) in any complete fiscal year prior to filing this registration with the Secretary of State? 9. Yes No State the total amount of capital raised by the business as of the date of the filing of this application: 10. If this is a renewal application, state the amount of capital listed raised by the business as of the date of this filing that is a "qualified investment" as defined under S.C. Code of Laws §11-44-30(6). The amount reported for past years should reflect the amount of qualified investments that were determined to be eligible for tax credits by the South Carolina Department of Revenue. a) Amount of qualified investments received in 2013: b) Amount of qualified investments received in 2014: c) Amount of qualified investments received in 2015: d) Amount of qualified investments received in 2016: 11. State the total number of persons currently employed by the business: 12. State the total number of full-time, part-time, and temporary jobs that have been created by the business and the average wages paid by those jobs: Position Number employed Average wage The applicant herewith declares that he or she has read the above and foregoing application and knows the contents thereof, and swears or affirms that the facts set out herein are true and correct. Sworn to and subscribed before me Signature of Applicant this _____ day of ___________, 20___. Date of Signature Notary Public of South Carolina Printed Name of Applicant My Commission Expires: Full-Time Part-Time Temporary Title Telephone Number Email Address Form Revised February 2016 American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS 1. If the space in this application is insufficient, please attach additional sheets containing a reference to the appropriate paragraph in the application. Please note that the Secretary of State's Office cannot provide legal advice or assist with the completion of this application. It is recommended that this application be completed under the guidance of an attorney or certified public accountant. Please note that this application should be submitted for the purpose of participation in the tax credit program provided under the High Growth Small Business Job Creation Act. This form should not be filed in lieu of Articles of Incorporation, Articles of Organization as a limited liability company, or an Application for a Certificate of Authority to Transact Business by a foreign corporation or foreign limited liability company. Upon receipt of the application, the Secretary of State's Office will review the application to determine if the business meets the requirements of a "qualified business" under the High Growth Small Business Job Creation Act of 2013 (South Carolina Code of Laws §11-44-10 et. seq.) If the application is accepted, the Secretary of State's Office will issue the applicant a letter certifying that the business is registered as a qualified business with the Secretary of State. Certification as a qualified business is effective for twelve (12) months from the date it issued. If the Secretary of State finds that any of the information contained in the application is false, the Secretary of State will revoke the registration of the business. The application for registration as a qualified business should be sent to the following address: Secretary of State ATTN: Legal Division 1205 Pendleton Street, Suite 525 Columbia, SC 29201 2. 3. 5. 6. 7. Form Revised February 2016 American LegalNet, Inc. www.FormsWorkFlow.com