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STATE OF SOUTH CAROLINA SECRETARY OF STATE MARK (South Carolina Department of Labor, Licensing and Regulation)

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STATE OF SOUTH CAROLINA
SECRETARY OF STATE
MARK HAMMOND
REGISTRATION AND/OR BIENNIAL RENEWAL
APPLICATION OF BUSINESS OPPORTUNITY
DISCLOSURES REQUIRED BY SOUTH CAROLINA LAW
“The State of South Carolina has not reviewed and does not approve, recommend, endorse or sponsor any
business opportunity. The information contained in this disclosure has not been verified by the State. If
you have any questions about this investment, see an attorney before you sign a contract or agreement.”
[] NEW [] RENEWAL of Business Opportunity Number ___________(Renewals Only)
1. Name of seller (list all names under which the seller has done, is doing, or intends to do business)
__________________________________________________________________________________
__________________________________________________________________________________
2. The name of the registered agent is ______________________________________________________
3. The street address of the registered agent is _______________________________________________
In the city of ____________________________________, SC _______________________________
(Zip Code)
4. List names, addresses, and titles of seller’s officers, directors, trustees, general partners, general
managers, principal executives, and other persons charged with responsibility for the seller’s business
activities relating to the sale of business opportunities.
Name Address Title
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. The length of time the seller has:
a) Sold business opportunities _______________________________________________________
b) Sold business opportunities involving the product, equipment, supplies, or services currently
being offered to the
purchaser_________________________________________________________
6. Include a full and detailed description of the actual services that the business opportunity seller
undertakes to perform for the purchaser.
7. Include a copy of a financial statement not older than 13 (thirteen) months of the seller, updated to
reflect any material changes in the seller’s financial condition which shall either be an audited
statement or shall be stated under penalty of perjury by the seller or his agent.
8. Is training of any type promised by the seller?
[] Yes [] No
If yes, please submit a complete description of the training and length of training. If a fee is to be
charged for such training, the seller set forth in detail an itemization of all costs to be covered by the
fee _______________________________________________________________________________
9. Does the seller promise services to be performed in connection with placement of equipment, product
or supplies at various locations?
[] Yes [] No
If yes, please submit your disclosure statement, setting forth full nature of these services, nature of
agreements to be made with owners or managers of these locations where the purchaser’s equipment,
product or supplies will be placed _______________________________________________________
10. Is the business opportunity seller required to secure a bond or establish a trust deposit pursuant to § 39-
57-40?
[] Yes [] No
If yes, please complete either of the following:
a) “As required by South Carolina law, the seller has secured a bond issued by _________________
__________________________________________________________________________________
a surety company authorized to do business in this State. Before signing a contract to purchase this
business opportunity, you should check with the surety company to determine the bond’s current
status.” Or
b) “As required by South Carolina law, the seller has established a trust account number ___________
__________________________________________________________________________________
(please include name and address of the bank or savings institution)
11. If the seller fails to deliver the product, equipment or supplies necessary to begin substantial operation
of the business within forty-five days of the delivery date stated in your contract, you may notify the
seller in writing and demand that the contract be canceled.
12. Does the seller make any statement concerning sales earnings, or range of sales or earnings that may be
through this business opportunity?
[]Yes [] No
If yes, please include disclosure of the following:
a) The total number of purchasers of business opportunities involving the product, equipment, supplies
or services being offered who to the seller’s knowledge have actually received earnings in the amount
or range specified, within three years prior to the date of the disclosure statement _________________
b) The total number of the purchasers of business opportunities involving the product, equipment,
supplies or being offered within three years prior to the date of the disclosure statement____________
DATE ______________________ _______________________________________
(Name of business Opportunity)
BY:____________________________________
(Signature)
___________________________________
(Name of Seller)
FILING INSTRUCTIONS:
1. This form must be filed by the last day of the month in which the registration expires.
2. If the space in this form in insufficient, please attach additional sheets containing a reference to the appropriate
paragraph in this form.
3. Filing Fee (Payable to the Secretary of State at the time of filing this application)-$100.00.
Form Approved by South Carolina Secretary of State 4/98
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STATE OF SOUTH CAROLINA SECRETARY OF STATE MARK (South Carolina Department of Labor, Licensing and Regulation)

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Completed 8 June 2021

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