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Application For License To Operate Employment Agency - South Carolina

Application For License To Operate Employment Agency Form. This is a South Carolina form and can be used in Non-Profit Corporation Secretary Of State .
 Fillable pdf Last Modified 7/13/2006
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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 No Denied (B) If so, was license granted or denied? Granted 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:_________
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