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NATION SAFE DRIVERS
SOUTH CAROLINA
COVER SHEET
MOTOR CLUB REPRESENTATIVE APPOINTMENT PROCEDURE
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2) If you answer “
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Court Order & Sentence Release Form, otherwise the application will be
rejected.
3) FORM MUST BE NOTARIZED
4) ALL MOTOR CLUB REPRESENTATIVES MUST BE ABLE TO ANSWER
“
YES”ON QUESTION 8.
(If a representative is not familiar with the provisions of South Carolina Motor
Club Service Act a copy will be provided to you upon request.)
5) FEE - $20.00 per applicant annually.
 RENEWS YEARLY ON APRIL 30TH.
Please make sure that with all new appointments youi
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address, telephone number, fax number, and e-mail address.
The same rules and fees apply to both resident and non-resident producers.
Make Checks Payable to Nation Safe Drivers and mail completed forms and fee to:
Nation Safe Drivers
Attention: Compliance Department
800 Yamato Road, Suite 100
Boca Raton, FL 33431
Revised 4/23/2012
STATE OF SOUTH CAROLINA
DEPARTMENT OF CONSUMER AFFAIRS
Mailing Address
P.O. Box 5757
Columbia, SC 29250-5757
INITIAL APPLICATION FOR INDIVIDUAL
MOTOR CLUB REPRESENTATIVE REGISTRATION
S.C. Code Ann. § 39-61-120 et seq.
www.scconsumer.gov
803-734-4291/800-922-1594
Street Address
2221 Devine St. Ste.200
Columbia, SC 29205-2418
Instructions
Applicant must return this completed form to sponsoring motor club company for submission with
Appointment, License Fee, etc. Do not leave blank spaces on this form. In the event information
requested is inapplicable, please note this by marking n/a for not applicable.
Note: This form must be completed for each company you represent.
REPRESENTATIVE INFORMATION
Last Name:
First Name:
Middle Name:
Telephone No.:
SSN:
Drivers License No.
Present
Street
State Issued:
RESIDENCE ADDRESS
City
State
Zip
County
Previous
Name
NAME AND ADDRESS OF MOTOR CLUB BEING REPRESENTED
Street
City
State
Address
Nation Safe Drivers
800 Yamato Road, Suite 100
FL
33431
APPLICANT PERSONAL HISTORY
Place of Birth
Parent’s Name
Father:
Mother: (Maiden)
Date of Birth
Type of
School
Boca Raton
ZIP
EDUCATIONAL BACKGROUND
Name and
Course of
Address of School
Study
High
School
College
Other
(Specify)
Motor Club Representative Registration
Revised 04/11
Page 1 of 2
Years Attended
From
Thru
Graduate
Yes
No
EMPLOYMENT EXPERIENCE
(Last Five Years Only)
List Current or Most Recent Experience First
Employer’s Name and
Address
Business Type
Date of
Employment
From
To
Positions or
Duties
Reason for
Termination
QUESTIONS
1.
Are your, or, have you been, licensed as a motor club representative in any State?
If yes, list states.
2.
Have you had a license suspended or revoked by any governmental agency?
If yes, when and by whom?
3.
Have you had a representative contract cancelled by a motor club?
If yes, list company and reason for cancellation.
4.
Have you been charged with irregularities or shortages in your accounts or
transactions with a motor club?
5.
Have you been convicted of a violation of any law other than minor traffic
violations in the last ten years?
If yes, give details.
6.
How much time will you devote to motor club business?
7.
Describe the training you have received to offer motor club services.
8.
Are you familiar with the provisions of the South Carolina Motor Club Services Act
that relate to motor club representatives, and to Unfair Trade Practices in the
motor club business?
Yes
No
APPLICANT’S CERTIFICATION
I, ___________________________, the applicant, do solemnly swear that all information
and answers contained in this application are complete, true and correct to the best of my
knowledge.
SWORN AND SUBSCRIBED to and before me
this _____ day of _______________, 20___
____________________________________
Notary Public
My Commission Expires: ________________
Motor Club Representative Registration
Revised 04/11
Page 2 of 2
______________________________
Signature of Applicant
STATE OF SOUTH CAROLINA
DEPARTMENT OF CONSUMER AFFAIRS
Mailing Address
P.O. Box 5757
Columbia, SC 29250-5757
MOTOR CLUB REPRESENTATIVE APPOINTMENT
SUMMARY
www.scconsumer.gov
803-734-4291/800-922-1594
Street Address
2221 Devine St. Ste. 200
Columbia, SC 29205-2418
Date:
Company Name
Street Address
Mailing Address
City/State/Zip
Nation Safe Drivers
800 Yamato Road, Suite 100
800 Yamato Road, Suite 100
Boca Raton, FL 33431
SSN
Name of Representative
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Total number of representatives ___
_____
and enclosed. $__
_____ (@$20.00 per representative) = total fee due
Failure to remit total fees due will result in return of applications
Please attach all appointments to this Summary
For Department Use Only
Motor Club Representative Summary
Revised 04/11
Page 1 of 1