ࡱ>  @ bjbj00  RbRb<Ut8888DlHlHlH8HIdDpLN(OOOQSkTxooooooo$rRtouXwQ^QXXo88OO[?p]]]Xv8OOo]Xo]]:Fc,6cOK lHLYXrc e Up0p|cRuYuc$,8888cucTU]mVVTTTooDDd*/n]DD/ STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS ATHLETIC AGENT EMPLOYEE FORM RENEWAL S.C. Code Ann. 59-102-10 et seq. (Supp. 2004)  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov 803-734-4236/800-922-1594 Please type or print legibly. In order for your application to be processed, complete all of the following questions. Incomplete information could result in delay or denial of your application. You may only complete this form if you have previously filed an Athlete Agent Employee Form. FILE BY MAY 7TH  DO NOT FAX THIS FORM FORMTEXT      Registration No.1.Applicant s Name: FORMTEXT       FORMTEXT       FORMTEXT      (Last)(First)(Middle)2.Company Name: FORMTEXT      (Current Employer)3.Residence Address: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      (City)(State)(Zip)4.Work Telephone:( FORMTEXT    )  FORMTEXT     -  FORMTEXT     5.Home Telephone:( FORMTEXT    )  FORMTEXT     -  FORMTEXT     6.Date of Birth: FORMTEXT   / FORMTEXT   / FORMTEXT     (mm/dd/yyyy)7.SSN: FORMTEXT    - FORMTEXT   - FORMTEXT     YESNO8. FORMCHECKBOX  FORMCHECKBOX Since the last application, has the business type for the organization changed? If yes, attach details, including the name of the school, dates attended, and degree obtained.9. FORMCHECKBOX  FORMCHECKBOX Has there been any change in your employment? If yes, attach details. 10. FORMCHECKBOX  FORMCHECKBOX Have you received further pertinent training or experience? If yes, attach details. 11. FORMCHECKBOX  FORMCHECKBOX Has there been any change to the states, colleges, or universities to which you are registered or licensed? If yes, attach details, including the name of the licensing organization, state, expira6tion date and license number. 12. FORMCHECKBOX  FORMCHECKBOX Have there been any changes to the Background Questions? (#15-#20 on the Athlete Agent Employee Form).13. FORMCHECKBOX  FORMCHECKBOX Would you like to change any of the listed references? If yes, attach the names and addresses of the new references and who you would like them to replace. 14. FORMCHECKBOX  FORMCHECKBOX Have you acted as an Athlete Agent to any student athlete since your last application? If yes, complete the spaces below and attach additional sheets as necessary. STUDENT ATHLETESPORTTEAM FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        The undersigned swears or affirms and certifies that he/she has completed and/or reviewed all information in this application and that all information contained herein and in all addending and supplemental forms is true and accurate. 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The undersigned acknowledges the duty and agrees to update and correct this information as it changes. SWORN TO AND SUBSCRIBED before methis ___________ day of ____________________, 20__Signature FORMTEXT      Notary Public For Print name, Business Relationship or TitleMy Commission Expires: The South Carolina Freedom of Information Act may require the Department to release this form as a public record; however, personal identifying inbQVbb$$7$8$H$Ifa$gd% & p@ P !d$7$8$H$Ifgdk:xkdh<$$Ifl\ aM*uX tP+44 labQVbb$$7$8$H$Ifa$gd% & p@ P !d$7$8$H$Ifgdk:xkd#=$$Ifl\ aM*uX tP+44 labQVbb$$7$8$H$Ifa$gd% & p@ P !d$7$8$H$Ifgdk:xkd=$$Ifl\ aM*uX tP+44 labQibb$$7$8$H$Ifa$gd% & p@ P !d$7$8$H$Ifgdk:xkd>$$Ifl\ aM*uX tP+44 la  ,8>57̾̎}o}Z}o}}HFH}U#h%htM5CJOJQJ^JaJ)hhtMB*CJ OJQJ^JaJ phhtMCJOJQJ^JaJ h%htMCJOJQJ^JaJ.jhehCJ OJQJU^JaJ mHnHu/j+@hehhehCJ OJQJU^JaJ hehCJ OJQJ^JaJ #jhehCJ OJQJU^JaJ h\YhtMCJ OJQJ^JaJ h [htMCJOJQJ^JaJ bQibb$$7$8$H$Ifa$gd% & p@ P !d$7$8$H$Ifgdk:xkdp?$$Ifl\ aM*uX tP+44 la:<>bTVT Vbb $7$8$H$IfgdmH% & p@ P !d$7$8$H$Ifgdk:xkd@$$Ifl\ aM*uX tP+44 latOA_VAI VOO $7$8$H$IfgdmH% & p@ P !d$7$8$H$Ifgdk:kdxA$$Iflr paM*ug  tP+44 latOAiOO $7$8$H$Ifgd:v% & p@ P !d$7$8$H$Ifgdk:kdsB$$Iflr @ aM*u7 !  tP+44 la67bbb% & p@ P !d$7$8$H$Ifgdk:xkdRC$$Ifl\ aM*uX tP+44 laformation will be released only if required by law.  Athlete Agent Employee Form - Renewal Rev. 10/06 Page  PAGE 1 of  NUMPAGES 2 Mailing Address P.O. 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