ࡱ> @ bjbjצצ Ne{{{86|~,)  $(LLLnd f f f f f f $RX Yo|oo LL o LLd od X`6L |<{ ( 0) 4w wPNhwg,  LzU&Ip zU STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS PROFESSIONAL EMPLOYER ORGANIZATIONS S.C. Code Ann. 40-68-10 et seq.  HYPERLINK "http://www.state.sc.us/consumer" www.state.sc.us/consumer (803) 734-4200 PROFESSIONAL EMPLOYER ORGANIZATION CONTROLLING PERSON APPLICATION (The Controlling Person must complete all parts of this Application) A separate form and $100 application fee is required for each Controlling Person. South Carolina law defines a Controlling Person as: (1) an officer or director of a corporation seeking to offer professional employer services, a shareholder holding ten percent or more of the voting stock of a corporation seeking to offer professional employer services, or a partner of a partnership seeking to offer professional employer services; (2) an individual who possesses, directly or indirectly, the power to direct or cause the direction of the management or policies of a company seeking to offer professional employer services through the ownership of voting securities, by contract or otherwise, and who is actively involved in the daytoday management of the company; or (3) an individual employed, appointed, or authorized by a business seeking to offer professional employer services to enter into a contractual relationship with a client company on behalf of the business. To be qualified to serve as a controlling person of a PEO licensee, a person must be at least eighteen (18) years of age, be of good moral character, and have educational, managerial, or business experience relevant to operation of a business entity offering PEO services, and at least two years of other related industry experience as approved by the department before the initial license is issued. The term good moral character means a personal history of honesty, trustworthiness, fairness, a good reputation for fair dealing, and respect for the rights of others and for the laws of this State and nation. As required by South Carolina law, the Department conducts a background investigation of each Applicant for a Controlling Person License to determine whether the Applicant meets the requirements of the law. The investigation includes the submission of fingerprints for processing through appropriate local, state, and federal law enforcement agencies; and if necessary, examination by the Department, of police or other law enforcement records maintained by local, state, or federal law enforcement agencies. The investigation also includes an examination of the Applicants credit history. The Department may deny an application for the issuance or renewal of a license if it finds that a controlling person is not qualified under this chapter. Conviction of a crime does not automatically disqualify a controlling person, require the revocation of a license, or require the denial of an application for a new or renewed license. Name of PEO or PEO Group: 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      Web Site: FORMTEXT       Full Name of Controlling Person: 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       Applicant's present or proposed position with PEO 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 controlling persons licensed with this renewal application will be forwarded to the Division upon the issuance of each controlling persons 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 South Carolina law requires any person applying for licensure as a PEO controlling person to have at least two years of related industry experience as approved by the Department before a license is issued. Please complete the schedule below pertaining to employment, accounting for all periods of time for at least the past seven (7) 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. If you believe that any of the listed employment satisfies the requirement for prior related industry experience, please emphasize that in the brief description of that job. Use extra copies of page 6 if necessary. 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       Applicant Business 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 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 PEO or PEO Group with which you have been involved or in which you owned an interest ever been refused a license, registration, or certification as a PEO, PEO group, or controlling person, or renewal thereof, in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Have you or any PEO or PEO Group 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 ever been involved in or owned an interest in a PEO or PEO group that has been adjudicated bankrupt, filed proceedings under the Bankruptcy Act, or has otherwise closed due to insolvency?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Are any of the licenses, registrations, or certifications of any PEO or PEO group 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 a PEO or PEO group 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 a PEO or PEO group that has had a lien or levy placed against it?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. Have you ever been involved in or owned an interest in a PEO or PEO group 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 or any PEO or PEO Group with which you have been involved or in which you owned an interest ever been the subject of any state or federal government investigation or audit regarding the payment of wages or taxes; the funding or administration of any employee benefit plan or workers compensation program; employment practices; licensing or registration; or any other matter arising out of a complaint filed by an employee, client, insurer, regulator or another PEO?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Have you ever been the subject of a governmental investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Are you or any PEO or PEO Group with which you have been involved or in which you owned an interest currently disputing any material obligations to an insurance carrier, benefit administrator or trust, or taxing authority?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 12. Is there any litigation or legal proceeding currently pending or threatened in any jurisdiction or territory in the United States against any PEO or PEO Group with which you have been involved or in which you owned an interest?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 13. Are you or any PEO or PEO Group with which you have been involved or in which you owned an interest delinquent, as of the date of application, with respect to any of its obligations of payroll, payroll related taxes, workers compensation insurance or employee benefits in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 14. 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FORMCHECKBOX  Yes  FORMCHECKBOX  No Continuing Education  SEQ CHAPTER \h \r 1Pursuant to S.C. Code Ann. 40-68-45, effective for license years beginning after September 30, 2005, key management personnel of all licensees must complete at least eight (8) hours of continuing professional education annually. If the licensee (PEO) is a sole proprietorship or partnership, key personnel means any controlling person. If the licensee is a corporation, key personnel means any person who both directs or causes the direction of the management of a company operating in South Carolina and is directly responsible for the day-to-day management of the company's operations in South Carolina. Using these criteria, will you be required to meet the continuing professional education requirement?  FORMCHECKBOX  Yes  FORMCHECKBOX  No ADDITIONAL INFORMATION In addition to completing this form, the following items are required to complete the application process: * Three Controlling Person Character Reference forms for each new controlling person. Form PEO-06. Character references cannot be given by a person who is a family member of the Applicant; employed by the Applicant or (his/her) company; an officer of a client company of the Applicants company; an existing or proposed controlling person of the Applicants company; or anyone who derives a profit from any relationship with the Applicant or the Applicants company. The reference must state that the Applicant is a person of good moral character, which is defined as a person with a personal history of honesty, trustworthiness, fairness, a good reputation for fair dealing, and respect for the rights of others and for the laws of this State and nation. * Two Fingerprint Cards for each new controlling person. Due to the Departments arrangement with the South Carolina State Law Enforcement Division (SLED), the fingerprints must be on the cards obtained from the Department. Please e-mail a request for the appropriate number of cards to  HYPERLINK "mailto:peoreg@dca.state.sc.us" peoreg@dca.state.sc.us and include your name and mailing address, or call (803) 734-4251. * Background Check. South Carolina law requires the Department to conduct a background investigation of each Applicant. SLED will conduct a criminal background check using the fingerprint cards requested above. In addition, each controlling person Applicant must obtain 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 companys 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: PEO Licensing and 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 my application for licensure as a controlling person.  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 Application, 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 license. 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 Application should be submitted to: South Carolina Department of Consumer Affairs Attn: PEO Licensing and 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. PEO Controlling Person Application SCDCA Form PEO-03 Rev. 02/06 Page  PAGE 1 of  NUMPAGES 10 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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