ࡱ>  @ Pbjbj5*5* W@W@>jtttt8twz$ ҇(*ݑ$OR\5U^[SX`6z tX ( i0 PXDՙsL4$IP#Ż P STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS DISCOUNT MEDICAL PLAN ORGANIZATIONS S.C. Code Ann. 40-68-10 et seq.  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov (803) 734-4200 DISCOUNT MEDICAL PLAN ORGANIZATION MANAGEMENT BIOGRAPHICAL AFFIDAVIT (Each member of management must complete a separate Affidavit) Name of DMPO: FORMTEXT      Mailing Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Street Address (if different): FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No. FORMTEXT      Website: FORMTEXT       Affiant s Full Name: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No. FORMTEXT      E-Mail Address: FORMTEXT      Home Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Date of Birth: FORMTEXT      Place of Birth: FORMTEXT      Social Security Number: * FORMTEXT       Have you ever been known by any other name? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide full name(s). FORMTEXT      Are you a citizen of the United States? FORMCHECKBOX  Yes  FORMCHECKBOX  NoAre you a citizen of another country? FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, what country? FORMTEXT       Government ID # if not a U.S. citizen: FORMTEXT       Affiant's present or proposed position with DMPO is:  FORMCHECKBOX  OwnerOwnership % FORMTEXT       FORMCHECKBOX  Officer FORMCHECKBOX  Director FORMCHECKBOX  Manager FORMCHECKBOX  Other: FORMTEXT       * Compliance Note: The Family Independence Act of 1995 required the South Carolina Department of Social Services Child Enforcement Division (Division) to operate a license revocation program for the purpose of enforcing and establishing child support. In accordance with this Act, South Carolina law ( 20-7-944) requires that all licensing entities submit to the Division licensee data for all new and renewal licenses issued. Therefore, identifying information (i.e., name, social security number and date of birth, etc.) for all management licensed with this application will be forwarded to the Division upon the issuance of each license. Personal information will not be used for any other purpose and is not subject to disclosure under the South Carolina Freedom of Information Act. South Carolina Code 30-4-10 et seq. Please list all residence addresses prior to your current address for the past 10 years beginning with the most recent: Beginning - Ending Dates (MM/YY)Street Address/Apt.#CityState or CountryPostal Code FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Education and Training 1. Please complete the schedule below pertaining to the schools you have attended starting with high school. Include all schooling, even if you did not graduate. Name/Address of SchoolDates Attended (MM/YY)Degree/Type of DiplomaDid you Graduate? (Yes or No)Your name if different FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       2. Provide details of any other training or education not listed above: Name/Address of the Institution/OrganizationDates Attended (MM/YY)Degree/Certification Obtained FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Employment Information Please complete the schedule below pertaining to employment, accounting for all periods of time for at least the past ten (10) years, whether compensated or otherwise (up to and including present jobs, positions, partnerships, owner of an entity, administrator, manager, operator, directorates or officerships). Please list the most recent first. Employer Name and Address FORMTEXT      Dates of Employment MM/YY FORMTEXT      Title/Position Held FORMTEXT      Your name if different FORMTEXT      Supervisor/Contact FORMTEXT      Telephone FORMTEXT      Brief Description of Job Responsibilities: FORMTEXT       Employer Name and Address FORMTEXT      Dates of Employment MM/YY FORMTEXT      Title/Position Held FORMTEXT      Your name if different FORMTEXT      Supervisor/Contact FORMTEXT      Telephone FORMTEXT      Brief Description of Job Responsibilities: FORMTEXT       Employer Name and Address FORMTEXT      Dates of Employment MM/YY FORMTEXT      Title/Position Held FORMTEXT      Your name if different FORMTEXT      Supervisor/Contact FORMTEXT      Telephone FORMTEXT      Brief Description of Job Responsibilities: FORMTEXT       Employer Name and Address FORMTEXT      Dates of Employment MM/YY FORMTEXT      Title/Position Held FORMTEXT      Your name if different FORMTEXT      Supervisor/Contact FORMTEXT      Telephone FORMTEXT      Brief Description of Job Responsibilities: FORMTEXT       Employer Name and Address FORMTEXT      Dates of Employment MM/YY FORMTEXT      Title/Position Held FORMTEXT      Your name if different FORMTEXT      Supervisor/Contact FORMTEXT      Telephone FORMTEXT      Brief Description of Job Responsibilities: FORMTEXT       Employer Name and Address FORMTEXT      Dates of Employment MM/YY FORMTEXT      Title/Position Held FORMTEXT      Your name if different FORMTEXT      Supervisor/Contact FORMTEXT      Telephone FORMTEXT      Brief Description of Job Responsibilities: FORMTEXT       PERSONAL History If any question is answered  Yes , please attach separate page(s) detailing the circumstances (including any applicable details such as state, license number, dates, etc.) 1. Have you ever been charged with, indicted for, plead guilty to, plead nolo contendere, convicted, or found guilty of any misdemeanors or felonies (with the exception of minor traffic violations) in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Have you or any organization with which you have been involved or in which you owned an interest ever been refused a license, registration, certification, or renewal thereof, in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Have you or any organization with which you have been involved, or in which you owned an interest, ever had any type of license revoked, suspended, or otherwise acted against (including probation, fine, or reprimand) in a disciplinary action in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Have you, or any organization with which you have been involved, or in which you owned an interest, ever been adjudicated bankrupt, filed proceedings under the Bankruptcy Act, or has otherwise closed due to insolvency?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Are any of your licenses, registrations, certifications or those of of any organization with which you have been involved or owned an interest currently under investigation or currently pending disciplinary action in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. Have you ever been involved in or owned an interest in an organization that has ever failed to satisfy any tax liabilities?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. Have you ever been involved in or owned an interest in an organization that has had a lien or foreclosure action placed against it?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. Have you ever been involved in or owned an interest in an organization that has been the subject of an indictment or a cease and desist order in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Have you ever been, in the last ten (10) years, a party to any civil action involving dishonesty, breach of trust, or a financial dispute?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Have you ever been the subject of a governmental investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. 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FORMCHECKBOX  Yes  FORMCHECKBOX  No 12. Have you or any organization with which you have been involved or in which you owned an interest voluntarily surrendered its license, registration or certification to avoid further investigation in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 13. List any entity subject to regulation by an insurance regulatory authority or discount medical plan organization regulatory authority that you control directly or indirectly. The term  control (including the term  controlling ,  controlled by and  under common control with ) means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing ten percent (10%) or more of the voting securities of any other person.  FORMTEXT      Is any of the stock of any of the above entities pledged or hypothecated in any way? FORMCHECKBOX  Yes  FORMCHECKBOX  No 14. Do (Will) you or members of your immediate family individually or cumulatively subscribe to or own, beneficially or of record, ten percent (10%) or more of the outstanding shares of stock of any entity subject to regulation by an insurance regulatory authority or discount medical plan organization regulatory authority, or its affiliates? An  affiliate of, or person  affiliated with, a specific person, is a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified. If the answer is  Yes , please identify below the entity or entities in which the cumulative stock holdings represent 10 percent (10%) or more of the outstanding voting securities.  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT      Is any of the stock of any of the above entities pledged or hypothecated in any way? FORMCHECKBOX  Yes  FORMCHECKBOX  No 15. Attach a statement which fully discloses the extent and nature of any contracts or arrangements between the affiant and any individual who is responsible for conducting the applicant s affairs, including any possible conflicts of interest. ADDITIONAL INFORMATION In addition to completing this form, the following items are required: * Background Check. Each affiant should obtain a background check from a reputable company that includes a nationwide criminal  SEQ CHAPTER \h \r 1history search covering at least the last ten (10) years and a summarized credit report covering the last seven (7) years. There are many companies that provide this service.  SEQ CHAPTER \h \r 1Please notify the provider or note on your order form that your company s name must prominently appear on the report. The provider must send a copy directly to the Department addressed to: South Carolina Department of Consumer Affairs Attn: DMPO Regulation P.O. Box 5757 Columbia, SC 29250-5757 Authority to Release Information: By my signature below, I consent to the release of information to authorized officers, agents, and/or employees of the State of South Carolina which may include but not be limited to information concerning my past and present work; including my official personnel files; attendance records; evaluations; educational records including transcripts; military service; law enforcement records; and/or any personnel records deemed necessary. In addition, I consent to authorize appropriate officers, agents, and/or employees of the State of South Carolina to make inquiries of third parties such as credit bureaus. I further release the organization, educational entity, present and former employers, law enforcement organization, and all third parties from any and all claims of whatever nature that I may have as a result of any inquiry or response given to such inquiries made in connection with this Affidavit.  Affidavit of Applicant I swear or affirm and certify that I have completed and/or reviewed all information on this form and submitted with this Affidavit, and to the best of my knowledge and belief, all information contained herein is true, correct and complete; and that there are no material omissions of fact which would have a bearing upon the South Carolina Department of Consumer Affairs decision to grant the requested registration certificate. I further certify that I understand that giving false information constitutes cause for denial or revocation of the application and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes. Signature FORMTEXT      Date FORMTEXT      Type or Print your name and Title SWORN TO AND SUBSCRIBED before me this ________ day of _____________________, 20______ ________________________________________________ (SEAL) Notary Public For __________________________________ My Commission Expires: _____________________________The completed Affidavit should be submitted to: South Carolina Department of Consumer Affairs Attn: DMPO Regulation P.O. Box 5757 Columbia, SC 29250-5757 Do not fax this form. An original, signed and notarized form is required. 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. DMPO Management Biographical Affidavit SCDCA Form DMPO-03 Rev. 11/07 Page  PAGE 1 of  NUMPAGES 10 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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