Free form.PDF - South Carolina

Office of the South Carolina Secretary of State Designation of Registered Agent for Discount Drug Card Sellers
TYPE OR PRINT CLEARLY WITH BLACK INK:

Name and address of authorized seller of discount drug card(s): _________________________________ _________________________________ _________________________________ State and date of incorporation of seller if seller is a corporation: ________________________________ Name and physical address of designated South Carolina agent for service: _________________________________ _________________________________ _________________________________ South Carolina mailing address of designated agent: _________________________________ _________________________________ _________________________________ Signature of designated agent:

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Filing instructions: 1. 2. Two copies of this form, original and either a duplicate original or a conformed copy, must be filed. Must be signed by the designated agent. Secretary of State P.O. Box 11350 Columbia, SC 29211

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