Initial Application For License To Operate Employment Agency - South Carolina Secretary Of State Page 4
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59. Failure to surrender the license shall subject the licensee to a misdemeanor with a fine of not more than five
hundred dollars ($500.00) or imprisoned for not more than one year, or both. Each day of noncompliance
constitutes a separate offense.
Each applicant listed in questions #4 a-c must complete this certification:
I, the applicant, certify under the penalty of perjury, that I have read and understand each of the items above.
Furthermore, I certify that the information furnished in this application and all attached supplementary
information is true and correct to the best of my knowledge, information and belief.
Applicant: ____________________________________________
Title: ___________________
Signature: ____________________________________________
Date: ___________________
Applicant: ____________________________________________
Title: ___________________
Signature: ____________________________________________
Date: ___________________
Applicant: ____________________________________________
Title: ___________________
Signature: ____________________________________________
Date: ___________________
Applicant: ____________________________________________
Title: ___________________
Signature: ____________________________________________
Date: ___________________
Applicant: ____________________________________________
Title: ___________________
Signature: ____________________________________________
Date: ___________________
I, _____________________________________, an attorney duly licensed by the South Carolina Bar, hereby
certify that the employment agency to whose application for license this certificate is attached, has complied with
the requirements of S.C. Code Ann. §§ 41-25-10, et. seq., relating to the organization of employment agencies,
and, that in my opinion, the agency is organized for a lawful purpose.
_____________________________________
__________________
______________________
Signature
Date
Phone Number
_________________________________________________________________________________________
Address
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