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State of South Carolina Secretary of State Private Personnel Placement Services - License Renewal S.C. Code of Laws Section 41-25-10 et seq.
The undersigned Private Personnel Placement Service hereby renews its employment agency license under the Private Personnel Placement Services Act. The renewal fee in the amount of one hundred ($100) dollars is submitted with this license renewal. Agency Information Name of Agency: ______________________________________________________________________________________ Trade Name(s) of Agency (if any): ________________________________________________________________________ Physical Address of Agency: _____________________________________________________________________________ _____________________________________________________________________________________________________ Telephone Number: __________________________________ Fax Number: ___________________________________

Email Address: _______________________________________________________________________________________ Applicant Information Name of Applicant (Individual's Name): ___________________________________________________________________ Address of Applicant: __________________________________________________________________________________ ____________________________________________________________________________________________________ Telephone Number: __________________________________ Email Address: ________________________________

Manager Information Name of Person Directing and Operating Placement Activities: _________________________________________________ Address: ____________________________________________________________________________________________ ____________________________________________________________________________________________________ Telephone Number: ___________________________________ Email Address: ________________________________

Name of Previous Employer: ____________________________________________________________________________ Address of Previous Employer: __________________________________________________________________________ _____________________________________________________________________________________________________ Surety Bond Surety Bond ($3,000.00) - Bond Number: __________________________________________________________________ Issued To: ___________________________________________________________________________________________
(Agency) (Owner)

Issued By: ________________________________________________________

Expiration Date: __________________

Upon penalty of perjury I state that the foregoing is true and accurate to the best of my knowledge. _______________________________________________
(Name and Title) (Date)

__________________________________________________
(Name and Title) (Date)

Private Personnel Placement Services - License Renewal Oct 2007