ࡱ>  @ zjbjbj{{ _rpppp8\j:$D H!(!!!m$ y% &L9999999$;R=r9]+$^m$++9pp!![$:$.$.$.+:pR!!9$.+9$.$.63"5!8 pQl,:4e6<::0j:4@R><,R>85ppppR>5TY&r'$.()!Y&Y&Y&99. STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS PRESCRIPTION DRUG DISCOUNT CARD REGISTRATION S.C. Code Ann. 37-17-10 et seq.  HYPERLINK "http://www.state.sc.us/consumer" www.scconsumer.gov (803) 734-4200 Name of Business: FORMTEXT       Home Office/ Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT      Web Site: FORMTEXT      Contact Person: FORMTEXT      Address: FORMTEXT       Telephone No. FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       In addition to this registration form, you must provide: 1.A copy of the card or other purchasing mechanism or device provided to consumers, plus a copy of all advertisements, which must expressly state in bold and prominent type, prominently placed, that the discounts are not insurance. 2.A copy of the contract(s) that the business has with each participating pharmacy or pharmacy chain; or attach a certification that states the discounts are specifically authorized and the person has a separate contract with each pharmacy or pharmacy chain listed in conjunction with the card or other purchasing mechanism or device. 3.A list of all participating pharmacies in South Carolina. 4.A copy of the business Articles of Incorporation, a certified copy of Good Standing Certificate, and a copy of a foreign corporations Certificate of Authority to Transact Business in the State of South Carolina, as applicable.5.The name of the agent for service of process and documentation that the agent has been registered with the South Carolina Secretary of State. This item requires a completion of the Office of Secretary of State Designation of Registered Agent for Discount Drug Card Sellers form, which is available at  HYPERLINK "http://www.scsos.com/forms/miscellaneous/drugcard.pdf" www.scsos.com/forms/miscellaneous/drugcard.pdf. The Department requires an original copy of the form which has been certified by the Secretary of State. Therefore, you should file at least two original copies with the Secretary of State. 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.  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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. Prescription Drug Discount Card Registration Revised 07/05 Page  PAGE 1 of  NUMPAGES 2 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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