ࡱ> -/*+,'` гbjbjLULU U.?.?_Owjjj~BABABA8zAB<~lEI(IIILd O\gPkkkkkkk$mh pPkj:VIL^L:V:VkIIolXZXZXZ:VRIjIkXZ:VkXZXZ:\,H"j2]IE @]MxBAV] ^D l0l(] [pWt[p2]2]&[pjX],QVmRXZaS%TQQQkkY^QQQl:V:V:V:V~~~8BA~~~BA~~~  STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS APPLICATION FOR LICENSE TO SELL PRENEED FUNERAL CONTRACTS  HYPERLINK "http://www.scstatehouse.net/code/t32c007.htm" S.C. Code Ann. 32-7-10 et seq.  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov 803-734-4291/800-922-1594/803-734-4229 fax DO NOT FAX THIS FORM(An original, signed and notarized form is required)Name of Funeral Home: FORMTEXT      Funeral Home License No. FORMTEXT      Street Address of Funeral Home: FORMTEXT      Mailing Address of Funeral Home: FORMTEXT      Name of Funeral Director: FORMTEXT      Director License No. FORMTEXT      Director s Residence Address: FORMTEXT      Telephone, Fax, and Email of Funeral Home: FORMTEXT      Hours of Operation: FORMTEXT      List the names and addresses, both residence and place of business, of every member, officer or director of the Funeral Home.Name & Official TitleResidence AddressBusiness Address FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Is the funeral home named as a defendant in any lawsuit?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If the answer is yes, provide names of the plaintiffs, amount sued for, nature of or basis for litigation, and expected result (Attach a separate statement if necessary).  FORMTEXT      Have you ever had any funeral service or preneed license denied, suspended, revoked, surrendered or have you ever been disciplined by licensing authorities in this or any other state or jurisdiction.  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, attach a separate statement giving complete details. Are you presently subject to any judgment or liens?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If the answer is yes, provide details.  FORMTEXT      Has any monetary payment, including the sale of preneed insurance, ever been accepted at this location for the purpose of furnishing or providing future services or funeral merchandise?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, you are required to furnish the names, dates, and amounts of funds accepted (attach a separate statement if necessary).  FORMTEXT       Have any verbal or written agreements been made and/or payment accepted for future goods or services?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, you are required to furnish the names, dates, and amounts of funds accepted (attach a separate statement if necessary).  FORMTEXT      Is your funeral home incorporated?  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t_+644 la+ /h @ P !$`'0*$Ifgd|lMCHECKBOX  Yes  FORMCHECKBOX  No Is your funeral home registered with the South Carolina Secretary of State s Office?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, how is your name registered?  FORMTEXT      Is your funeral home owned by a holding company or another corporation?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, please provide details: Name of holding company: FORMTEXT      Address: FORMTEXT      Contact person: FORMTEXT      Telephone No. FORMTEXT     -  FORMTEXT     -  FORMTEXT     Number of services that you performed in the previous calendar year: FORMTEXT      How many preneed contracts do you expect to sell in a year if you are licensed?  FORMTEXT     Also Enclosed:Filing Fee FORMCHECKBOX ($250.00)Financial Statement FORMCHECKBOX Credit Report FORMCHECKBOX Release Authorization FORMCHECKBOX Bond or Letter of Credit FORMCHECKBOX Insurance Company or Bank: FORMTEXT      Number: FORMTEXT      Original or certified, true copy of Certificate of Existence if South Carolina corporation FORMCHECKBOX orThe original or certified, true copy of Certificate of Authority to do Business in South Carolina if non-South Carolina corporation. FORMCHECKBOX This is to certify that the above information is true and correct. Note: Any false or misleading answers to any application questions shall be grounds for revocation of the license. Signature of ApplicantDateSWORN to before me this _____ day of __________, A.D. 20___(L.S.)Notary Public for South CarolinaMy Commission Expires:     Preneed Application Rev. 03/11 Page  PAGE 1 of  NUMPAGES 2 Mailing Address P.O. 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