Scel Retailer License Application - South Carolina Education Lottery Licensing Department Page 4
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8SCEL Retailer License Application
Schedule A
– Page 1 -
Owner Information
Step 1:
ATTENTION:
Renewal forms are pre-printed (make corrections as necessary). Please type or print Information clearly using a pen.
Application Type
For renewals, has the
Write the Company Name/ Owner
NOTE: If the business “type” is registered as a Sole
Business type or
Name / Legal Entity Name / Sole
Proprietorship with the State, write your personal name
ownership changed
New License
Proprietor name used when filing
here. Otherwise, write the name of the company in this
since the last renewal?
taxes for this company.
space and write the name of the retail store on Schedule B.
Renewal License
If yes, fill out Schedule C
N
Changing Owners
YES
O
Sec 2.
1
OWNER’S COMPANY STREET ADDRESS
OWNER’S MAILING ADDRESS
CITY, COUNTY
CITY, COUNTY,
STATE ZIP
STATE, ZIP
PHONE NUMBER & EXT
FAX NUMBER
CELL PHONE
Step 2:
When you registered the business with the State of SC, what business type did you select? (Check one)
CORPORATION
PARTNERSHIP
TAX ID,
-
LIMITED LIABILITY CORP
LIMITED PARTNERSHIP
Fed ID,
2
Or
UNINCORP. ASSOCIATION
LIMITED LIABILITY PARTNER
Empl. ID
IF SOLE PROPRIETORSHIP, ENTER
-
-
SOLE PROPRIETORSHIP
YOUR SOCIAL SECURITY NUMBER
3
all owners, partners,
Step 3
: Who are
associated with the business?
NOTE:
FAILURE
to list all owners may be grounds for denial or revocation of license.
Use Schedule C to list additional owners.
•
Partnership, Limited Partnership, or Limited Liability Partnership:
List all partners and limited partners irrespective of the amount of interest held in the partnership.
This section
•
Corporation: List all officers and all directors. List all shareholders with 10% or more ownership interest.
must be
•
completed.
Limited Liability Corporation: List all members and/or member-managers.
•
Sole Proprietorship: List the sole person who owns the business.
FIRST NAME
MIDDLE NAME
LAST NAME
MAIDEN NAME
BUSINESS TITLE
CHECK ONE
DATE
MONTH
DAY
YEAR
SOCIAL
-
-
OF
MALE
FEMALE
SECURITY
__ __/ __ __/ __ __
BIRTH
NUMBER
FIRST NAME
MIDDLE NAME
LAST NAME
MAIDEN NAME
BUSINESS TITLE
SOCIAL
DATE
MONTH
DAY
YEAR
CHECK ONE
-
-
SECURITY
OF
__ __/ __ __/ __ __
MALE
FEMALE
NUMBER
BIRTH
FIRST NAME
MIDDLE NAME
LAST NAME
MAIDEN NAME
BUSINESS TITLE
DATE
MONTH
DAY
YEAR
CHECK ONE
SOCIAL
-
-
OF
__ __/ __ __/ __ __
MALE
FEMALE
SECURITY
BIRTH
NUMBER
Step 4:
Is the headquarters of the business located outside of South Carolina? If so, please fill out this section (Section 4)
IF THE LEGAL ENTITY IS HEADQUARTERED OUTSIDE OF SOUTH CAROLINA OR IF THE BUSINESS IS NOT ORGANIZED PURSUANT TO SOUTH CAROLINA LAW, PER
SCEL REGULATION, THE APPLICANT MUST IDENTIFY THE HIGHEST RANKING EMPLOYEE OF THE BUSINESS WHO IS A SOUTH CAROLINA RESIDENT. THIS PERSON
MAY, BUT IS NOT REQUIRED TO ALSO ACT AS OPERATIONAL MANAGER. THIS PERSON MUST UNDERGO A CRIMINAL BACKGROUND INVESTIGATION.
FIRST NAME
MIDDLE NAME
LAST NAME
PHONE NUMBER
BUSINESS TITLE
4
ADDRESS
CITY,
STATE
ZIP
SOCIAL
DATE
CHECK ONE
MONTH
DAY
YEAR
-
-
SECURITY
OF
MALE
FEMALE
__ __/ __ __/ __ __
NUMBER
BIRTH
Rev. 010106 -- SC Education Lottery Application -- Page 1 of 5
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