Business Name: ___________________________________________________________________
Address: _________________________________________________________________________
Person Responsible/Owner Name:_____________________________________________________
Phone: ____________________________ Email: ________________________________________
Brief Description of Business: _________________________________________________________
Signature/Title: _________________________________________________ Date: _____________
200 N. 12th Street • West Columbia, SC 29169 • (803) 939-8601 •
Please submit form to:
West Columbia City Hall
Attn: Face Mask Waiver
200 N. 12th Street
West Columbia, SC 29169
or email it to:
Once the waiver is received, you will receive a placard acknowledging receipt of registration.
Please display the placard in the front window/door of your business.
I, ________________________, certify that ________________________ can
eectively social distance customers and employees without the use of face coverings
and opt-out of the Emergency Face Covering Ordinance.
Print Name Business Name