ࡱ> sur@ 2Abjbj buuLr::::   8BL=Hp.[\0->/>/>/>Cr>CG$IRKG9o^G::[G["["["R:R->["->["["*P"9" `9  9 .i9~;| H0=H9Lg L$9::::L9["GGD?" STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS REPRESENTATIVE REGISTRATION CANCELLATION MOTOR CLUB SERVICES S.C. Code Ann. 39-61-120 (d)  HYPERLINK "http://www.state.sc.us/consumer" www.scconsumer.gov 803-734-4253/800-922-1594 Company Name FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      City/State/Zip FORMTEXT      It is requested that the representative s registration for the below-named representative be cancelled.Last Name: FORMTEXT      SSN: FORMTEXT      First Name: FORMTEXT      Middle Name: FORMTEXT      Request Made By: (Check One) FORMCHECKBOX Company FORMCHECKBOX S.C. Department of Consumer Affairs REASON FOR CANCELLATION FORMTEXT       NOTE: Notice of termination of any club representative s authority to act on behalf of the club must be sent to this Department in writing within thirty (30) days of termination. 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I hereby certify the above information is true and correct. SWORN AND SUBSCRIBED to and before me this _____ day of _______________, 20___ ____________________________________ ___________________________________ Notary Public Signature Authorized Appointing Officer My Commission Expires: ________________ For Department Use OnlyDate Received:Date Approved:Company Code: Motor Club Representative Cancellation Revised 02/04 Page  PAGE 1 of 1 Mailing Address P.O. 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