Individual Professional Solicitor Registration Statement Form - State Of South Carolina Secretary Of State Page 3

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I, the registrant, certify under the penalty of perjury, that I have read and I understand each of the items #8 through
#12, and I have initialed each item accordingly.
I, the registrant, certify under the penalty of perjury, that the statements made in this document and in any
accompanying papers are true to the best of my knowledge and belief.
_________________________________________________
Signature of Registrant
_________________________________________________
Title
_________________________________________________
Date
NOTES
1.
This statement and accompanying documentation are a public record, copies of which will be provided
upon request to any interested person.
2.
Pursuant to §33-56-145 (B), any person who knowingly and willfully violates the provisions of this chapter
or who knowingly and willfully gives false or incorrect information to the Secretary of State is guilty of a
misdemeanor.
3.
Please refer to S.C. Code § 33-56-110 (1976) as amended for complete description of all registration
requirements.
FILING INSTRUCTIONS
1.
Type or print in ink the answer to all applicable items. Enter "NA" for any item which is not applicable.
2.
A mandatory fee of $50.00 payable to the Secretary of State must accompany this statement.
3.
If there is insufficient space on this form for answers, attach additional sheet(s) with reference to the
question number for which you are answering.
X:\FORMS\EXTERNAL\Individual Solicitor Registration.DOC Rev. 3/27/2002 12:49 PM

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