ࡱ> ;=6789: @ /bjbjPP 7q::@Fr$PL D0(XXXjJftvvvH $ R?  ^j XX RXXttb"X 0[͌sv4~ 0 $  {l$%lSTATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS APPLICATION FOR A CERTIFICATE OF AUTHORITY PHYSICAL FITNESS SERVICES (INITIAL FILING) DCA-PF-1 S.C. Code Ann. 44-79-10 et seq. (Supp. 1997)  HYPERLINK "http://www.state.sc.us/consumer" www.scconsumer.gov 803-734-4246/800-922-1594 All forms are available on our website For Office Use OnlyProvide All Information Requested Below:Filing year FORMTEXT     Business Name and Address FORMTEXT      Type of Business (check one)Print Name In Which Business is Displayed to Public FORMTEXT      Corporation FORMCHECKBOX Corporate Name (if applicable)LLC FORMCHECKBOX  FORMTEXT      Partnership FORMCHECKBOX Physical AddressSole Ownership FORMCHECKBOX  FORMTEXT       FORMTEXT    FORMTEXT      (City)(State)(Zip) FORMTEXT      Mailing Address FORMTEXT       FORMTEXT    FORMTEXT      (City)(State)(Zip) FORMTEXT      First Filing Yes  FORMCHECKBOX  No  FORMCHECKBOX Telephone Number of Business FORMTEXT      E-Mail Address FORMTEXT       Print Name of Contact Person at BusinessNameBirthdate and Social Security Number if sole proprietor or partnership FORMTEXT       FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT     THIS INFORMATION IS REQUIRED UNDER THE "FAMILY INDEPENDANCE ACT OF 1995"Types of Services and/or Facilities Offered (Check as many as apply) FORMCHECKBOX Health Spa (HP) FORMCHECKBOX Tanning Salon(TS) FORMCHECKBOX Martial Arts(MA) FORMCHECKBOX Water Exercise (AE) FORMCHECKBOX Weight Loss(WL) FORMCHECKBOX Exercise Clubs(EC) FORMCHECKBOX Athletic Club (AC) FORMCHECKBOX Personal Training (PT)Answer each question belowCheck OneYesNoBusiness Activity Information1.Did you begin providing physical fitness services in South Carolina after June 24, 1980? FORMCHECKBOX  FORMCHECKBOX 2.Do you use prepaid or credit contracts that run for more than three months? (written or oral)  FORMCHECKBOX  FORMCHECKBOX 3.Answer a. or b.a.Do you use prepaid or credit contracts (excluding personal training contracts) having a total cost of more than two hundred ($200) dollars? (written or oral) FORMCHECKBOX  FORMCHECKBOX b.If you are a personal trainer, do you use prepaid or credit contracts having a total cost of more than three hundred ($300) dollars? (written or oral) FORMCHECKBOX  FORMCHECKBOX 4.If you answered yes to Question 2 above, will your gross business receipts exceed $150,000 this calendar year? (Gross volume is the amount reported to the IRS) FORMCHECKBOX  FORMCHECKBOX 5.Do you assign, discount or sell contracts to third parties? FORMCHECKBOX  FORMCHECKBOX 6.How many members do you anticipate will be enrolled, by this time next year, at the location whose address appears above? FORMTEXT     7.How many physical fitness services locations do you have in this State? If only one location, enter (1)   FORMTEXT     8.Did you answer  yes to Question (1) and answer  yes to Question (2) or Question (3)? FORMCHECKBOX  FORMCHECKBOX If your answer to this question is yes you are required by law to demonstrate financial responsibility. If you answered no proceed to Line 11. 9.Which method of demonstrating financial responsibility do you propose to use? Surety Bond  FORMCHECKBOX  Letter of Credit  FORMCHECKBOX  Financial Responsibility10.If you plan to use either a surety bond or letter of credit place a checkmark next to the category which describes your center and amount of assurance. CategoryNumber of CentersNumber of MembersAssurance AmountCheck OneAMultiple CenterAny Number$25,000 FORMCHECKBOX BSingle Center300 + Members$25,000 FORMCHECKBOX CSingle Center200 - 299 Members$20,000 FORMCHECKBOX DSingle Center100 - 199 Members$15,000 FORMCHECKBOX ESingle Center1 - 99 Members$10,000 FORMCHECKBOX 11.Multiply the number which appears on Line 7 by $50.00.This is the amount you owe:$  FORMTEXT      I certify that all information and answers contained in all parts of this application are complete, true and correct to the best of my knowledge. Also, I agree to abide by all the provisions of the Physical Fitness Services Act and to comply with requests for information made by the S.C. Department of Consumer Affairs. All information provided herein is subject to verification.Remit ToSouth Carolina Department of Consumer Affairs P.O. Box 5757 Columbia, S.C. 29250-5757PLEASE READ INSTRUCTION SHEET CAREFULLY ____________________________________ Owner/Manager Signature ____________________________________ Date ____________________________________ Please Print LIST OF PHYSICAL FITNESS CENTERS INSTRUCTIONS NOTE: Complete this attachment only if your answer to question 7 was two or more. Enter the present name and address of each center along with the name and telephone number of the contact person for that center. 1. FORMTEXT       FORMTEXT      Business NameName of Contact Person FORMTEXT      ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Physical AddressTelephone Number FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT     City StateZipCountyNumber of Members2. FORMTEXT       FORMTEXT      Business NameName of Contact Person FORMTEXT      ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Physical AddressTelephone Number FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT     CityStateZipCountyNumber of Members3. FORMTEXT       FORMTEXT      Business NameName of Contact Person FORMTEXT      ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Physical AddressTelephone Number FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT     CityStateZipCountyNumber of Members4. FORMTEXT       FORMTEXT      Business NameName of Contact Person FORMTEXT      ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Physical AddressTelephone Number FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT     CityStateZipCountyNumber of Members5. FORMTEXT       FORMTEXT      Business NameName of Contact Person FORMTEXT      ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Physical AddressTelephone Number FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT     CityStateZipCountyNumber of Members6. FORMTEXT       FORMTEXT      Business NameName of Contact Person FORMTEXT      ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Physical AddressTelephone Number FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT     CityStateZipCountyNumber of MembersUSE ADDITIONAL SHEETS IF NEEDED PLEASE READ INSTRUCTIONS CAREFULLY Physical Fitness Services"Physical fitness services" means facilities or services for the development of physical fitness through exercise or weight control. The term includes the facilities and services of health or exercise centers, clubs, studios, or classes; health spas, weight control centers, clinics or studios; figure salons, tanning centers; and athletic or sport clubs which provide tennis, racquet or handball courts, gymnasiums or swimming pools. It does not include rehabilitative therapy administered by a licensed physical therapist.Application for Certificate of Authority1.All organizations wishing to provide Physical Fitness Services in this State must first obtain a Certificate of Authority from the Administrator of the S.C. Department of Consumer Affairs. Applications must be accompanied by the following: *a surety bond or letter of credit, if required; *a certified copy of its charter or articles of incorporation and its bylaws, if any;*if a corporation, a certified copy of a certificate of existence from the Secretary of State of South Carolina; (Copies may be obtained by contacting the Secretary of State's office at (803) 734-2158.) *a copy of its membership agreement, if any; *a copy of any contracts to be issued, if any; *certificate of authority fee. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSEDExpiration of CertificateCertificates of Authority expire on each December 31st and must be renewed if you wish to continue providing physical fitness services in this State.Contract RequirementsIf you use a prepaid or credit contract at your center, that contract must conform to the requirements set by state law ( 44-79-30, 44-79-40, 44-79-50). CONTRACTS NOT MEETING THE REQUIREMENTS OF STATE LAW WILL RESULT IN THE RETURN OF THIS APPLICATION. A copy of these contract requirements is enclosed. FeeThis application must be accompanied by a certificate of authority fee in the amount of $50.00 per center. FAILURE TO REMIT THS FEE WILL RESULT IN THE RETURN OF THIS APPLICATION.InformationIf you need assistance with completing this application form or have any questions about the Physical Fitness Services Act 44-79-10 et seq., please call the S.C. Department of Consumer Affairs at (803) 734-4246 or 1-800-922-1594.  Bond No.__________________ SPECIAL DEPOSIT BOND State of ____________________, KNOW ALL MEN BY THESE PRESENTS. That the undersigned ______________________ as principal of __________________________ and the undersigned ______________________ as surety, of ________________________ are firmly held and bound unto the Administrator of the Department of Consumer Affairs of the State of South Carolina in full and just sum of _____________ dollars, to which payment we bind ourselves and our respective successors and assigns jointly and severally. Sealed with our seals and dated at ____________________ this __________ day of ______________ in the year of our Lord, two thousand and ________________. WHEREAS, Section 44-79-80 of the Code of Laws of South Carolina, 1976 as amended, requires that a physical fitness center deposit and thereafter continuously maintain a bond in an amount determined by the Administrator. The bond is to be executed by a surety company authorized by the laws of this State to transact business in South Carolina and must be for the use of the State as well as any member that may have a cause of action against the physical fitness services center. AND WHEREAS, the undersigned principal ________________________ aforesaid, desires to transact business within the State of South Carolina in accordance with the terms of its laws and to deposit with the Administrator a good and solvent bond in the sum of _____________________ dollars, does by this instrument furnish that bond. NOW, THEREFORE, the condition of this bond is such that if the above principal has failed to comply with the S.C. Physical Fitness Services Act, S.C. Code 44-79-10, et seq. (LAW CO-OP 1986) or has failed to provide contracted for physical fitness services to customers as determined by the Administrator after notice and opportunity for hearing, then we the Beneficiary (South Carolina Department of Consumer Affairs) are entitled to the sum of ________________. PROVIDED, HOWEVER, that liability hereunder may be terminated either (a) by written notice, from the surety to the Administrator, that liability shall terminate upon the expiration of forty-five (45) days from the date of such notice, or (b) upon written authorization mailed to the surety by the Administrator. 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' ( * ] _ } ~      )!*!+!C!D!E!;埑;rfhHCJOJQJaJhHhHCJOJQJaJhHhH5CJOJQJaJhrzCJOJQJ^JaJ hPhrzCJOJQJ^JaJh+9CJOJQJaJUheh1rCJOJQJaJheCJOJQJaJh:XCJOJQJaJheheCJOJQJaJhHCJOJQJaJ(II= ~     *!C!D!E!g!h!!!!("""""Q#$5$5$5$5$5$5$50*50*50*50*50*50*50*50*50*50*50*5 1$`gdH1$gdH$a$gdH $1$a$gde p@ p1$^`pgde1$gdeIn the presence of witness as to Surety: Name of Surety: _____________________________ ______________________________ _____________________________ By: __________________________ (President (Officer) EXECUTION BY PRINCIPAL AND SURETY MUST BE PROBATED ON REVERSE SIDE WITNESS AS TO PRINCIPAL STATE OF _______________________, ________________________ COUNTY. Before me, the subscribing Notary Public, personally appeared _________________________________ (Witness number one (see front of bond) and made oath that he/she saw the within named _________________________________________________ Company, represented by _______________________________________________ sign, seal, and deliver the within Bond, and that he/she with __________________________________ subscribed their names as (Witness number two (see front of bond) witness thereto. __________________________________________ To be signed by witness one or two (see front of bond) Sworn to and subscribed before me this _____ day of __________ A.D., 20_______. ______________________________________(L.S.) My Commission Expires: ______________________ WITNESS AS TO SURETY STATE OF __________________________, ____________________________COUNTY. Before me, the subscribing Notary Public, personally appeared _________________________________ (Witness number two (see front of bond) and made oath that he/she saw the within named _________________________________________________ Company represented by __________________________________________ sign, seal, and deliver the within Bond, and that he/she with ________________________________ subscribed their names as witness thereto: (Witness number two (see front of bond) ____________________________________________ To be signed by witness one or two (see front of bond) Sworn to and subscribed before me this _____ day of __________ A.D., 20_______. ______________________________________(L.S.) My Commission Expires: ______________________ PHYSICAL FITNESS SERVICES IRREVOCABLE DOCUMENTARY LETTER OF CREDIT MODEL FORM(Bank Name and Address on Bank Letterhead)Applicant:(Applicant Name)(Applicant Address)Beneficiary:South Carolina Department of Consumer Affairs3600 Forest DriveP.O. Box 5757Columbia, SC 29250Letter of Credit No.Expiration Date: Dear Sir: We hereby issue this documentary letter of credit in your favor which is available against beneficiarys draft at sight drawn on (bank name) , bearing the clause drawn under documentary letter of credit number _________________________ accompanied by the following documents: 1. Beneficiarys signed statement addressed to the applicant, stating: (applicants name) has failed to comply with the S.C. Physical Fitness Services Act, S.C. Code 44-79-10 et seq. (LAW CO-OP 1986) or has failed to provide contracted for physical fitness services to customers as determined by the Administrator after notice and opportunity for hearing. We are therefore entitled to the sum of $ ____________________ drawn under letter of credit number ________________________, Or 2. Beneficiarys signed statement addressed to the applicants stating that (applicants name) has not replaced this letter of credit number ____________ with another letter of credit or other evidence of financial responsibility acceptable to the Administrator within 45 days of the expiration date of the credit, and we are therefore entitled to the sum of $__________________ drawn under letter of credit number ____________________. ______________________________ (Signature of authorized bank officer) (Title) Initial Application Revised 01/09 Page  PAGE 7 of  NUMPAGES 7 Mailing Address P.O. 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