Renewal Application For License To Operate Employment Agency - South Carolina Secretary Of State Page 4

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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: ___________________
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