ࡱ>  @ bjbjFF ,,Yrrrrr"="="=8Z=>,EpN@F(,F,F,FHMSP\zzzzC2{Z$R~QH^HQQ~rr,F,F[WWWQ:rR,F,FzWQzWWM_P"-o,FB@ ()d"=QRn~p 0Eo;R8$-orrrr-oWQQQ~~/4$sW4 STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS INITIAL APPLICATION FOR INDIVIDUAL MOTOR CLUB REPRESENTATIVE REGISTRATION S.C. Code Ann. 39-61-120 et seq.  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov 803-734-4253/800-922-1594 Instructions Applicant must return this completed form to sponsoring motor club company for submission with Appointment, License Fee, etc. Do not leave blank spaces on this form. In the event information requested is inapplicable, please note this by marking n/a for not applicable. Note: This form must be completed for each company you represent. REPRESENTATIVE INFORMATIONLast Name: FORMTEXT      Telephone No.: FORMTEXT      First Name: FORMTEXT      SSN: FORMTEXT      Middle Name: FORMTEXT      Drivers License No. FORMTEXT      State Issued: FORMTEXT   RESIDENCE ADDRESSPresentStreetCityStateZipCounty FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT      Previous FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT      NAME AND ADDRESS OF MOTOR CLUB BEING REPRESENTEDNameStreet AddressCityStateZIP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT      APPLICANT PERSONAL HISTORYDate of BirthPlace of BirthParent s Name FORMTEXT       FORMTEXT      Father: FORMTEXT      Mother: (Maiden) FORMTEXT      EDUCATIONAL BACKGROUNDType of SchoolName and Address of SchoolCourse of StudyYears AttendedGraduateFromThruYesNoHigh School FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX College  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Other (Specify) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  EMPLOYMENT EXPERIENCE (Last Five Years Only) List Current or Most Recent Experience First Employer s Name and AddressBusiness TypeDate of EmploymentPositions or DutiesReason for TerminationFromTo FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       QUESTIONSYesNo1.Are your, or, have you been,9A̼}jXF7$%h(hZyN5>*CJOJQJ]aJhZyN5CJOJQJ]aJ"hH^:hZyN5CJOJQJ]aJ"hH^:hZyN5CJOJQJ\aJ%hH^:hZyN5>*CJOJQJ\aJ3jhZyN5>*CJOJQJU\aJmHnHu(jhH^:hZyNCJUaJmHnHuhZyNB*CJOJQJaJphhCB*CJOJQJaJphhhZyNCJOJQJaJhZyNCJOJQJaJ0jhhZyNCJOJQJUaJmHnHu 9]     s L N $pA$pA$L$L$L$L$L$0$x$5$5$5$5$$5gd5$0$d %d &d 'd N O P Q ]^`0a$gd=$a$gd %d O gdZyN8   ɱvaL40hZyN/hH^:hZyN0J56:;CJOJQJ\aJ)h:L0J56:;CJOJQJ\aJ)hKhK0J56CJOJQJ\aJ hKhK0JCJOJQJaJ+jhKhKCJOJQJUaJ&hKhK0J6CJOJQJ]aJ/jhKhK0J6CJOJQJU]aJ)hZyN0J56:;CJOJQJ\aJ%h(hZyN5>*CJOJQJ]aJhZyN5CJOJQJ]aJ  N V  . 0 D F H R T t v ĺ笢z笢fz笢Rz'jhl=hTCJOJQJU'jhl=hTCJOJQJU&jhl=CJOJQJUmHnHu'jhl=hTCJOJQJUhl=CJOJQJjhl=CJOJQJUhL,CJOJQJhL,hL,5CJOJQJhL,5CJOJQJhCCJOJQJhCJOJQJhh5CJOJQJ      $5455?5 5$Ifgdl??kd$$Ifl$h% th%44 la$$Ifa$gdL,l?  . 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FORMCHECKBOX  FORMCHECKBOX If yes, list states. FORMTEXT      2.Have you had a license suspended or revoked by any governmental agency?  FORMCHECKBOX  FORMCHECKBOX If yes, when and by whom?  FORMTEXT      3.Have you had a representative contract cancelled by a motor club? FORMCHECKBOX  FORMCHECKBOX If yes, list company and reason for cancellation.  FORMTEXT      4.Have you been charged with irregularities or shortages in your accounts or transactions with a motor club? FORMCHECKBOX  FORMCHECKBOX 5.Have you been convicted of a violation of any law other than minor traffic violations in the last ten years? FORMCHECKBOX  FORMCHECKBOX If yes, give details.  FORMTEXT      6.How much time will you devote to motor club business?  FORMTEXT      7.Describe the training you have received to offer motor club services.  FORMTEXT      8.Are you familiar with the provisions of the South Carolina Motor Club Services Act that relate to motor club representatives, and to Unfair Trade Practices in the motor club business? FORMCHECKBOX  FORMCHECKBOX  APPLICANT S CERTIFICATION I, ___________________________, the applicant, do solemnly swear that all information and answers contained in this application are complete, true and correct to the best of my knowledge. SWORN AND SUBSCRIBED to and before me this _____ day of _______________, 20___ ____________________________________ ______________________________ Notary Public Signature of Applicant My Commission Expires: ________________ Motor Club Representative Registration Revised 03/07 Page  PAGE 1 of  NUMPAGES 2 Mailing Address P.O. 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