ࡱ> QSNOP @ sbjbjʚʚ k||||888<<<8< =Vhf@^C4CCCItQLTM9g;g;g;g;g;g;g$@jRlx_g8XTHIXTXT_g||CCg.YYYXT|C8C9gYXT9gYY!\68m\CZ@ 0p1<<:U9\] h<VhA\, mV: mm\L4"|||| m8m\@QNO0Y+QR9QNQNQN_g_g3F9DJY^F9 STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS CREDIT COUNSELOR RENEWAL APPLICATION INSTRUCTIONS S.C. Code Ann. 37-7-101 et seq.  HYPERLINK "http://www.scconsumer.gov/" www.scconsumer.gov 803-734-4236 Renewal applications must be postmarked by December 1st or the applicant will have to apply as new. If not renewing, notify the Department in writing.  Complete the Credit Counselor Renewal Application and all additional forms in their entirety. Incomplete, illegible, or faxed applications will not be accepted. Incomplete information could result in the delay or denial of your application. Please print or type the application information. Review: In order to accurately complete the RENEWAL application, verify the information the Department currently has on file concerning your Name, License Number, and the Organization and Locations where you are employed. This information is posted on the website under the Verification link. Criminal Record Check: The Department will not require criminal record checks for counselors, unless they are new. Otherwise, these checks will be done on a random basis or when deemed necessary. Applicants, however, are reminded of the duty to update information submitted to the Department, including criminal record data. Fees: All fees must accompany the application. Application Fee - $40 A fee of $40 must be sent with the application. All licenses expire annually on December 31st. Continuing Education: Twelve (12) hours of Continuing Professional Education (CPE) must be earned by December 31st of every other year of licensure (every 2nd renewal/ even-numbered renewal). If you are required to have obtained twelve hours of CPE for this renewal, please attach a CPE Reporting Form to the Renewal Application. Make Checks Payable To: South Carolina Department of Consumer Affairs Send Completed Applications To: SCDCA Legal Division: Credit Counseling P.O. Box 5757 Columbia, SC 29250-5757 Questions: Carri Grube Lybarker Staff Attorney 803-734-4297 Darlene Dinkins Program Coordinator 803-734-4209 STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS CREDIT COUNSELOR LICENSE RENEWAL APPLICATION S.C. Code Ann. 37-7-101 through - 122. www.scconsumer.gov 803-734-4236 DO NOT FAX THIS FORM(An original, signed and notarized form is required)See renewal application instructions. This form may be duplicated. Print legibly or type information requested on the form in its entirety. If any of the basic information on this form changes, submit an Application Change/ Update Form to the Department. Incomplete information could result in delay or denial of your application. When completing the application, attach additional page(s) as necessary. This form must be postmarked by December 1st.1.Company Name: FORMTEXT      Company License Number: FORMTEXT      (Current Employer)2.Address(es) Where Employed: FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT      (Street)(City)(State)(Zip Code)*All addresses where employed must be listed. Attach additional page as necessary3.Your Legal Name: FORMTEXT       FORMTEXT       FORMTEXT      (Last)(First)(Middle)Have you been known by any other name? FORMCHECKBOX YES FORMCHECKBOX NOIf yes, state the name: FORMTEXT      (Ex. Maiden name, etc.)4. Counselor License Number: FORMTEXT      5.Resident Address: FORMTEXT      How long at this address? FORMTEXT      (Street) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      (City)(State)(Zip Code)(County)6.Work Telephone Number:( FORMTEXT    )  FORMTEXT    - FORMTEXT     Home Telephone Number:( FORMTEXT    )  FORMTEXT    - FORMTEXT     7.Date of Birth: FORMTEXT   / FORMTEXT   / FORMTEXT     8.SSN: FORMTEXT    - FORMTEXT   - FORMTEXT     9.Driver s License Number: FORMTEXT      State and Date of Issue: FORMTEXT   Mark an X in the Appropriate BoxIf you answer YES to any question, attach a separate sheet giving complete details.YESNO10.Has there been any change to your personal information, educational background or employment background? (Please consult the Counselor Applications previously submitted.) FORMCHECKBOX  FORMCHECKBOX 11.Have you been convicted of a felony within the past ten years? Provide details about the offense, including conviction date, court, penalty and attach a certified copy of the Criminal Docket Sheet and the Presentence Investigation Report. FORMCHECKBOX  FORMCHECKBOX 12.Have you been convicted of an offense involving breach of trust, moral turpitude or dishonest dealings within the past ten years? Provide details about the offense, including conviction date, court, penalty and attach a certified copy of the Criminal Docket Sheet and the Presentence Investigation Report. FORMCHECKBOX  FORMCHECKBOX 13.Have you ever been charged with any irregularities or shortages in your business accounts or transactions? FORMCHECKBOX  FORMCHECKBOX 14.Have you been adjudicated as bankrupt?  FORMCHECKBOX  FORMCHECKBOX 15.Were you ever an owner, partner, director, officer, member, or manager of any firm or company which was adjudicated bankrupt or for which a receiver appointed either during the time or within one year after you were connected with it?  FORMCHECKBOX  FORMCHECKBOX YESNO16.Have you ever surrendered, resigned, cancelled, or been denied a professional license or other credential in ANY jurisdiction? Provide details, including the name of the profession, the agency, and the agency address. FORMCHECKBOX  FORMCHECKBOX 17.Has ANY licensing or other credentialing agency ever taken any disciplinary action against you, including, but not limited to, any warning, reprimand, suspension, probation, limitation, or revocation? Provide details, including the name of the agency and date of the action. FORMCHECKBOX  FORMCHECKBOX 18.Is disciplinary action pending against you in any jurisdiction? Provide details, including the name of the agency and status of the action. FORMCHECKBOX  FORMCHECKBOX  CONTINUING PROFESSIONAL EDUCATION (CPE) If you are required to have obtained twelve hours of CPE for this renewal, please attach a CPE Reporting Form to your Renewal Application.  VERIFICATION The information the Department currently has on file concerning my Name, License Number, and the Organization and Locations where I am employed was reviewed on _____/______/______. Is the information correct? 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I acknowledge that I have a duty and agree to update and correct this information as it changes. Additionally, I acknowledge that pursuant to S.C. Code 37-7-101 through 122, a criminal records check may be requested. FORMTEXT      Signature of Credit CounselorType or Print your name SWORN TO AND SUBSCRIBED before me this ______ day of ____________________, 20__ _________________________________________ Notary Public For ___________________________ My Commission Expires: ____________________ The South Carolina Freedom of Information Act may require the Department of Consumer Affairs to release this form as a public record; however personal identifying information will be released only if required by law.     PAGE  Renewal Credit Counselor Application Rev. 08/08 Page  PAGE 1 of  NUMPAGES 3 Mailing Address P.O. Box 5757 Columbia, SC 29250-5757 Street Address 3600 Forest Drive, 3rd Floor Columbia, SC 29204-4406 Z[\]^{%{/{%{ekdxA$$IflF(*{& t +    44 la($ & p@ P !d$7$8$H$Ifa$gd!q5% & p@ P !d$7$8$H$Ifgd($ & p@ P !d$7$8$H$Ifa$gd!q5^_`ab{%{/{%{ekdB$$IflF(*{& t +    44 la($ & p@ P !d$7$8$H$Ifa$gd!q5% & p@ P !d$7$8$H$Ifgd($ & p@ P !d$7$8$H$Ifa$gd!q5`abcfgqr NT$:T"#ʳdʡʡʡʡʡ>jh-B*CJOJPJQJU^JaJmHnHo(phu8jBh( h-B*CJOJQJU^JaJph#h-B*CJOJQJ^JaJph,jh-B*CJOJQJU^JaJph)hh-B*CJOJQJ^JaJph h-5CJ OJQJ\^JaJ h-CJOJQJ\^JaJ"bcdef{p{{{o/{($ & p@ P !d$7$8$H$Ifa$gd!q5% & p@ P !d$7$8$H$Ifgd($ & p@ P !d$7$8$H$Ifa$gd!q5a9{($ & p@ P !d$7$8$H$Ifa$gd!q5kd:C$$IflֈdZP(*HG t +44 laPRTp{{{v{O{kd/D$$IflrdZP*HN t +44 la% & p@ P !d$7$8$H$Ifgd{p{{{v{($ & p@ P !d$7$8$H$Ifa$gd!q5% & p@ P !d$7$8$H$Ifgd($ & p@ P !d$7$8$H$Ifa$gd!q58:t{L{7p{7p{7p{7p{$  $7$8$H$Ifa$gdb($ & p@ P !d$7$8$H$Ifa$gd!q5kdE$$IflrdZP*HN t +44 la#$%&p{p{p{p{{v{% & p@ P !d$7$8$H$Ifgd$  $7$8$H$Ifa$gdb#$& &'(*2TY_~~~~tntnj^O^Oh%vh.ICJ OJQJaJ h.ICJ OJQJaJ h.I h.I0Jjh.I0JUh;jh;Uh(|5CJOJQJ\h(|CJOJQJ h-5CJ OJQJ\^JaJ h-CJOJQJ\^JaJ,hh-5B*CJOJQJ^JaJph)hh-B*CJOJQJ^JaJph#h-B*CJOJQJ^JaJph(t]"r0*Vrrrrrrrri&`#$kdE$$IflrdZP*HN t +44 la ()*OZ|}~!9:JXpqrs0*i0*iVVVVVVVVVVVV0*Vgdw$a$gdw$a$_`fghimnxyz{|}~9:JpqrsʵʵݱxlhxlhdWh(|5CJOJQJ\h(|hwhwCJOJQJaJhw5CJOJQJaJUh.ICJH*OJQJaJh.ICJOJQJaJh.I5CJOJQJaJh;h.I(jh%vh.ICJ OJQJUaJ *$hCJ OJQJaJ mHnHu*h%vh.ICJ OJQJaJ %jh%vh.ICJ OJQJUaJ Street Address 3600 Forest Drive Columbia, SC 29204-4406 Mailing Address P.O. 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