Office of the South Carolina Secretary of State
Designation of Registered Agent for Non-Resident Wholesale
Prescription Drug Distributors
TYPE OR PRINT CLEARLY WITH BLACK INK
Pursuant to the provisions of Section 40-43-83(B) of the 1976 South Carolina Code of Laws, as amended,
the applicant delivers to the Secretary of State the following:
1. Name and address of non-resident wholesale prescription drug distributor:
__________________________________________________________
__________________________________________________________
__________________________________________________________
2. State and date of incorporation of wholesaler if wholesaler is a corporation:
__________________________________________________________
3. Name and physical address of designated South Carolina agent for service:
__________________________________________________________
__________________________________________________________
__________________________________________________________
4. South Carolina mailing address of designated agent:
__________________________________________________________
__________________________________________________________
__________________________________________________________
Signature of designated agent: ______________________________________
Filing instructions:
1.
Two copies of this form, original and either a duplicate original or a conformed copy, must be filed.
2.
Must be signed by the designated agent.
3.
$10.00 filing fee made payable to the Secretary of State’s Office.
Return to:
Secretary of State
1205 Pendleton Street
Suite 525
Columbia, SC 29201