ࡱ> NPKLM @ bjbj{{ :YIr((((YYY80Z[3: ^a(aaadgIiU--0$mRT)j/d^d)j)jT((aa[cmcmcm)jL(RaaUcm)jUcmcm!uPz"a^ ڂyYuj4q~y03CjC$((((Cxcm)j)j)jTT?TEGmTE STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS APPLICATION FOR CERTIFICATE OF AUTHORITY MOTOR CLUB SERVICES S.C. Code Ann. 39-61-40 et seq.  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov 803-734-4253/800-922-1594 Company Name FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      City/State/Zip FORMTEXT      Executive home office address if different than above FORMTEXT       1.Company is licensed to do business in the following states:a. FORMTEXT      d. FORMTEXT      b. FORMTEXT      e. FORMTEXT      c. FORMTEXT      f. FORMTEXT      2.Company has applications pending in the following states:a. FORMTEXT      d. FORMTEXT      b. FORMTEXT      e. FORMTEXT      c. FORMTEXT      f. FORMTEXT      3.Has the company s license ever been suspended or revoked by any state or states? If yes, attach detailed statement.  FORMCHECKBOX Yes FORMCHECKBOX No4.In what state(s) has the companys application ever been denied? a.___________________________d.____________________________b.___________________________e.____________________________c.___________________________f.____________________________5.Has the company ever been licensed in South Carolina? If yes, give dates and reason for withdrawal.  FORMCHECKBOX Yes FORMCHECKBOX NoDatesReason FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      6.List names of affiliated companies, if any, and indicate which are licensed in South Carolina. AffiliatesYesNo FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  7.List companies which are owned or controlled, directly or indirectly by applicant company.a. FORMTEXT      d. FORMTEXT      b. FORMTEXT      e. FORMTEXT      c. FORMTEXT      f. FORMTEXT      8.If applicant company is a subsidiary, wholly or substantially, of another company, give parent company s names, state of domicile and nature of parent s principal business.  FORMCHECKBOX  Yes FORMCHECKBOX  NoNameState Nature of principal business FORMTEXT        FORMTEXT    FORMTEXT      9.List the names of officers and/or directors who beneficially own 10% or more of the company s stock and the amount owned by each at the date of this applicationOfficer/DirectorAmount Owneda. FORMTEXT       FORMTEXT      b. FORMTEXT       FORMTEXT      c. FORMTEXT       FORMTEXT      10.Were any of the applicant company s officers or directors associated as an officer or director with any company at the time said company s license was suspended or revoked or at the time said company was placed in receivership? If yes, please attach a complete explanation, giving names of officer or director, name of former company, etc.  FORMCHECKBOX  Yes FORMCHECKBOX  NoPLEASE SUBMIT THE FOLLOWING WITH YOUR INITIAL APPLICATIONa.A certified copy of your charter, articles of incorporation and by-laws. b.If a corporation, a certified copy of your certificate of existence from the South Carolina Secretary of State. (Copies of articles and certificate of existence may be obtained by contacting the South Carolina Secretary of States Office at (803) 734-2158. If you are a corporation not domiciled in South Carolina, you must apply for registration as a foreign corporation. c.A copy of your most recent financial statement, certified by two principal officers.d.Your plan of doing business to include:1.Membership application;2.Membership certificate and member identification card;3.Individual insurance policy or group certificate; and4.Service contracts. THIS APPLICATION MUST BE ACCOMPANIED BY A CERTIFICATE OF AUTHORITY FEE IN THE AMOUNT OF $500.00 AND A BOND IN THE AMOUNT OF $50,000 OR OTHER SECURITIES, OR LETTER OF CREDIT. FAILURE TO REMIT THE FEE WILL RESULT IN RETURN OF THE APPLICATION. REMIT FEE AND APPLICATION MATERIALS TO: SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS P.O. BOX 5757 COLUMBIA, SC 29250-5757 APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE KNOW ALL MEN BY THESE PRESENTS, That _______________________________________, a corporation not domiciled in this State having a certificate of authority to transact business in this State hereinafter called Corporation, has made, constituted and appointed, and does hereby make and constitute and appoint the Administrator, Department of Consumer Affairs of the State of South Carolina, and his successors in office, to be its true and lawful attorney upon whom all legal process in any action or proceeding against it shall be served and further agrees that any lawful process against it which is served upon such attorney shall be of the sale legal force and validity as if served upon the Corporation. 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This instrument shall be construed as to constitute full compliance with Section 30-61-90 of the South Carolina Code, 1976 and shall be executed pursuant thereto. IN WITNESS WHEREOF, said Corporation in pursuance of a resolution duly adopted by its Board of Directors, has caused this instrument to be executed in its name by its President and Secretary, and its corporate seal to be hereunto affixed at the City of _____________________, State of _____________________, this _____ day of ______________. 20___. Attest:______________________________________________________________________SECRETARY(Name of Corporation)By:___________________________________PRESIDENT STATE OF))ss.COUNTY OF) This certifies that on the _____ day of _______________, 20___, before the undersigned Notary Public in and for the said County and State, personally appeared the above-named ______________________________, known to me to be the President and ______________________________, the Corporation mentioned in and which executed the foregoing power of attorney, and severally acknowledged that they executed the same by authority and in behalf of said Corporation, pursuant to a resolution of the Board of Directors of said Corporation duly adopted on the _____ day of _______________, 20___; and ______________________________, the Secretary of said Corporation, further acknowledged that the corporate seal thereto attached and impressed there in is the corporate seal of said Corporation and was affixed thereto by him. INTESTIMONY WHEREOF, I have hereunto set my hand and notarial seal the _____ day of _______________, 20___. My Commission Expires ___________________________________________________Notary PublicState of _____________________________ Motor Club Application Revised 08/04 Page  PAGE 1 of  NUMPAGES 4 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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