MEMORANDUM

TO: South Carolina Fire Equipment Dealer License Holders FROM: Ray Hoshall, Chief of Licensing and Permitting DATE: December 1, 2014 SUBJECT: Renewal of South Carolina Fire Equipment Dealer License Our records indicate that your current Fire Equipment Dealer license expires January 31, 2015. If renewal is desired, please submit the following items to the Office of State Fire Marshal prior to the expiration date:

1. A completed Fire Equipment Dealer License Application. For your convenience, an application is

enclosed. If additional copies are needed, applicants may also access renewal forms via our website at www.scfiremarshal.llronline.com.

2. A completed Employees Certified to Conduct Fire Extinguisher and Fixed System Services in South Carolina application. List all employees with current permits seeking renewal.

3. A completed Existing Employee Renewal for each employee listed on the Employees Certified to Conduct Fire Extinguisher and Fixed System Services in South Carolina form. For employees who are to be permitted to install or service pre-engineered systems, list the systems which they can service. These employees are required to have a current manufacturer’s training certificate from at least one manufacturer’s product being serviced, and a signed and notarized Permit Affidavit for any others.

4. A New Employee Fire Equipment Application and Permit Affidavit (to be completed only for new employees who will be taking an examination for certification or applying for an Apprentice Permit.)

5. A check in the amount of $200 for each company and $50 for each permit application made payable to the “State of South Carolina.” You may also renew licenses and permits using a credit card (Visa/MasterCard) by completing and returning at attached Credit Card Authorization Form.

6. A current Certificate of Insurance (not a Policy Declaration) from a company licensed to conduct business in South Carolina must be included with your application. The Certificate of Insurance must list the S.C. Office of State Fire Marshal as a Certificate Holder.

Please note: All incomplete application packages will returned to the applicant unprocessed. This could result in your completed application not being received by the expiration date. Pursuant to Subarticle 4 of the South Carolina State Fire Marshal’s Rules and Regulations, licenses and permits are valid for a period of two years. There is no grace period for renewal of licenses or permits. If renewal applications are not received by the expiration date, license applicants must follow all requirements for a new license. Permit applicants must retest before a new permit can be issued. License and permit fees are nonrefundable. Licenses and permits are not transferable. If a permit holder is no longer employed by the company listed on the permit, the licensee should attempt to obtain the permit card. If that cannot be accomplished, the licensee should notify the Office of State Fire Marshal so the permit can be canceled from the license. Should you have any questions or concerns, please do not hesitate to contact Ronnie Yonce at (803) 896-9802 or via email: veronica.yonce@llr.sc.gov.

South Carolina Department of Labor, Licensing, and Regulation Office of State Fire Marshal

141 Monticello Trail • Columbia, SC 29203 Phone: 803-896-9800 • Fax: 803-896-9806 • www.llronline.com

Licensing and Permitting Section

South Carolina Department of Labor, Licensing and Regulation

Division of Fire and Life Safety • Office of State Fire Marshal 141 Monticello Trail Columbia, S.C. 29203

Phone: 803-896-9800 • www.scfiremarshal.llronline.com

Fire Equipment Dealer License Application

Type of License: New Renewal License Class: A B C D

Fees: $200 per company/ $50 per employee

All licenses expire January 31, regardless of issue date.

The application will not be processed unless all required information is completed and the appropriate fee is submitted. Incomplete applications will be returned, resulting in processing delays. All affidavit signatures must be notarized. A current copy of your certificate of insurance must be attached. Date of Application: __________________________ Federal Tax I.D. #__________________________________ Company Name: __________________________________________________________________________ Owner of Company: __________________________________________________________________________ Internet Address: http://www.________________________________________________________________ Physical Business Address: ____________________________________________________________________ Street City State Zip

____________________________________________________________________ County Phone Fax Mailing Address (if different): _____________________________________________________________________ Is this firm incorporated a partnership or individually owned? Address of corporate office, if different from above: __________________________________________________ Insurance Certificate Attached? Yes No Do you have a: High Pressure Hydrostatic Testing Certificate? Yes (include DOT Certificate) No

DOT RIN (Retesters Identification Number)? Yes No

Manufacturers Company is permitted to service: _____________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

______________________________ ______________________ Signature of Applicant Title of Applicant

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EMPLOYEES CERTIFIED TO CONDUCT FIRE EXTINGUISHER & FIXED SYSTEM SERVICES IN SOUTH CAROLINA

NOTE: If an employee listed below has been disciplined or had a license suspended or revoked by a board/ commission administered by the S.C. Department of Labor, Licensing and Regulation (under section 40-1-80), you must submit an explanation of the final disposition on a separate page.

Name Social Security Number Indicate Permit Class Held Pre-Engineered Systems

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South Carolina Department of Labor, Licensing and Regulation

Division of Fire and Life Safety • Office of State Fire Marshal 141 Monticello Trail Columbia, S.C. 29203

Phone: 803-896-9800 • www.scfiremarshal.llronline.com

Fire Equipment Application Existing Employee Renewal

Permit Class: A B C D (submit current copy of Certificate of Training for “D”) Social Security: ________-________-________ Name: _______________________________________________________________

Last First Middle Date of Birth: ________/________/________

Month Day Year Driver’s License Number: ____________________ State: ___________ Home Address: ______________________________________________________________________ Street City County/ State Zip Email Address: ___________________________________________ Business Name: ___________________________________________ Business Address: _____________________________________________________________________ Street City County/ State Zip Phone: ________________________________________ I certify that I have carefully read and understand the provision of the State Fire Marshal’s Regulations, Subarticle 4, Portable Fire Extinguishers and Fixed Fire Extinguishing Systems, Sections 71-8303.1 through 71-8303.18. ____________________________________ _________________________________________ Signature of Applicant Date of Application

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AFFIDAVIT OF ELIGIBILITY

ALL applicants for a South Carolina license (after July 1, 2008) are required to complete and sign an Affidavit of Eligibility (8-29-10 S.C. Code of Laws). Section A: LAWFUL PRESENCE in the United States I, (print full name) ___________________________________, swear or affirm under penalty of perjury under the laws of the State of South Carolina that (check 1, 2 or 3 below): 1. I am a United States citizen or legal permanent resident 18 years of age or older; or 2. I am not a United States citizen but am lawfully present in the United States as evidenced by one of the following: a. I am a qualified alien as defined in 8 U.S.C. sec 1641, 18 years of age or older. b. I am a nonimmigrant under the “Immigration and Nationality Act,” Federal Public Law 82-414 as amended, 18 years of age or older. 3. I am not physically present in the United States under 8 U.S.C. sec 1621 (c) (2) (c) or employed in the

United States pursuant to 8 U.S.C. 1621 (c) (2) (a) (check either a or b below): a. I am a United States citizen, not physically present or employed in the United States. b. I am a Foreign National, not physically present or employed in the United States. If you select 3.a. or 3.b., you do not need to complete Section B. Skip to Section C. Section B: Secure and Verifiable Document (Must be completed if you checked number 1 or 2 in Section A). 1. Please check one of the following acceptable secure and verifiable documents. Complete documentation must be provided upon request only.

Any South Carolina Driver License, South Carolina Driver Permit or South Carolina Identification Card, expired less than one year.

Out-of-state issued photo driver's license or photo identification card, photo driver’s permit expired less than one year. State: _______________

Valid Temporary Resident Card Certificate of Naturalization with intact photo Certificate of United States Citizenship with intact photo Other: (Name of verifiable document) ___________________________________________________

2. Enter the state or the federal agency name where this secure and verifiable document was issued. __________________________________________________________________________________ (If issued by a state agency, include both the state and agency name.) 3. What is the secure and verifiable document number? _____________________________________ 4. What is the expiration date of your secure and verifiable document? ___________ (month/day/year) (If the document does not have an expiration date, i.e. military ID or naturalization certificate, write “N/A.”)

South Carolina Department of Labor, Licensing and Regulation Office of State Fire Marshal

141 Monticello Trail • Columbia, SC 29203 Phone: 803-896-9800 • Fax: 803-896-9806 • www.llronline.com

Name __________________________________

__________/_____/_________

Social Security Number* Section C: Attestation I understand that this sworn statement is required by law because I have applied for or hold a professional or commercial license regulated by 8 U.S.C. sec. 1621. I understand that state law requires me to provide proof that I am lawfully present in the United States. I may also be required to provide proof of lawful presence. I understand that in accordance with section 8-29-10 (S.C. Code of Laws) false statements made herein are punishable by law. I state under penalty of perjury that the above statements are true and correct. I am the person identified above and the information contained herein is true and correct to the best of my knowledge. I understand that under South Carolina law, providing false information is grounds for denial, suspension or revocation of a license, certificate, registration or permit. I understand that the above information must be disclosed to the Department of Labor, Licensing and Regulation upon request and is subject to verification. __________________________________________ ________________________________ Signature Date __________________________________________ Print name as shown on the secure and verifiable document. Professional License Type: ____________________________________ Current License Number (if applicable): ____________________________________ *The South Carolina Code of Laws requires that every individual who applies for an occupational or professional license provide a social security or alien identification number for use in the establishment, enforcement and collection of child support obligations and for reporting to certain databanks established by law. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Social security numbers may also be disclosed to other governmental regulatory agencies and for identification purposes to testing providers and organizations involved in professional regulation. Your social security number will not be released for any other purpose not provided for by law.

PERMIT AFFIDAVIT

I (applicant’s name) ___________________________, an employee of (company name)

_______________________ do hereby declare that I have the ability to obtain the proper

manufacturer’s installation and maintenance manuals and manufacturer’s parts for the

(manufacturer’s makes and model numbers) _____________________________________

pre-engineered fire extinguishing system(s), and I will have them in my possession when

performing all installations and/or maintenance.

I further testify that I will conduct all installations and/or maintenance in complete compliance

with the manufacturer’s installation and maintenance manuals with the exception of obtaining

a manufacturer’s training certificate. I understand that any violation of this affidavit will be

grounds for the revocation of my Class D fire equipment permit.

__________________________________ Applicant __________________________________ Date SWORN AND SUBSCRIBED TO BEFORE ME THIS _____ DAY OF ___________ 20____. _________________________________ NOTARY PUBLIC My commission expires: _____________ NOTE: Current Manufacturers Training Certificates must be on file in the OSFM for a Class “D” Permit.

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South Carolina Department of Labor, Licensing and Regulation

Division of Fire and Life Safety • Office of State Fire Marshal 141 Monticello Trail Columbia, S.C. 29203

Phone: 803-896-9800 • www.scfiremarshal.llronline.com

Fire Equipment Application New Employee

Permit Class: A B C D (submit current copy of Certificate of Training for “D”) Social Security: ________-________-________ Name: _______________________________________________________________

Last First Middle Date of Birth: ________/________/________

Month Day Year Driver’s License Number: ____________________ State: ___________ Home Address: ______________________________________________________________________ Street City County/ State Zip Email Address: ___________________________________________ Business Name: ___________________________________________ Business Address: _____________________________________________________________________ Street City County/ State Zip Phone: _________________________________________________ I certify that I have carefully read and understand the provision of the State Fire Marshal’s Regulations, Subarticle 4, Portable Fire Extinguishers and Fixed Fire Extinguishing Systems, Sections 71-8303.1 through 71-8303.18. ____________________________________ _________________________________________ Signature of Applicant Date of Application

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AFFIDAVIT OF ELIGIBILITY

ALL applicants for a South Carolina license (after July 1, 2008) are required to complete and sign an Affidavit of Eligibility (8-29-10 S.C. Code of Laws). Section A: LAWFUL PRESENCE in the United States I, (print full name) ___________________________________, swear or affirm under penalty of perjury under the laws of the State of South Carolina that (check 1, 2 or 3 below): 1. I am a United States citizen or legal permanent resident 18 years of age or older; or 2. I am not a United States citizen but am lawfully present in the United States as evidenced by one of the following: a. I am a qualified alien as defined in 8 U.S.C. sec 1641, 18 years of age or older. b. I am a nonimmigrant under the “Immigration and Nationality Act,” Federal Public Law 82-414 as amended, 18 years of age or older. 3. I am not physically present in the United States under 8 U.S.C. sec 1621 (c) (2) (c) or employed in the

United States pursuant to 8 U.S.C. 1621 (c) (2) (a) (check either a or b below): a. I am a United States citizen, not physically present or employed in the United States. b. I am a Foreign National, not physically present or employed in the United States. If you select 3.a. or 3.b., you do not need to complete Section B. Skip to Section C. Section B: Secure and Verifiable Document (Must be completed if you checked number 1 or 2 in Section A). 1. Please check one of the following acceptable secure and verifiable documents. Complete documentation must be provided upon request only.

Any South Carolina Driver License, South Carolina Driver Permit or South Carolina Identification Card, expired less than one year.

Out-of-state issued photo driver's license or photo identification card, photo driver’s permit expired less than one year. State: _______________

Valid Temporary Resident Card Certificate of Naturalization with intact photo Certificate of United States Citizenship with intact photo Other: (Name of verifiable document) ___________________________________________________

2. Enter the state or the federal agency name where this secure and verifiable document was issued. __________________________________________________________________________________ (If issued by a state agency, include both the state and agency name.) 3. What is the secure and verifiable document number? _____________________________________ 4. What is the expiration date of your secure and verifiable document? ___________ (month/day/year) (If the document does not have an expiration date, i.e. military ID or naturalization certificate, write “N/A.”)

South Carolina Department of Labor, Licensing and Regulation Office of State Fire Marshal

141 Monticello Trail • Columbia, SC 29203 Phone: 803-896-9800 • Fax: 803-896-9806 • www.llronline.com

Name __________________________________

__________/_____/_________

Social Security Number* Section C: Attestation I understand that this sworn statement is required by law because I have applied for or hold a professional or commercial license regulated by 8 U.S.C. sec. 1621. I understand that state law requires me to provide proof that I am lawfully present in the United States. I may also be required to provide proof of lawful presence. I understand that in accordance with section 8-29-10 (S.C. Code of Laws) false statements made herein are punishable by law. I state under penalty of perjury that the above statements are true and correct. I am the person identified above and the information contained herein is true and correct to the best of my knowledge. I understand that under South Carolina law, providing false information is grounds for denial, suspension or revocation of a license, certificate, registration or permit. I understand that the above information must be disclosed to the Department of Labor, Licensing and Regulation upon request and is subject to verification. __________________________________________ ________________________________ Signature Date __________________________________________ Print name as shown on the secure and verifiable document. Professional License Type: ____________________________________ Current License Number (if applicable): ____________________________________ *The South Carolina Code of Laws requires that every individual who applies for an occupational or professional license provide a social security or alien identification number for use in the establishment, enforcement and collection of child support obligations and for reporting to certain databanks established by law. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Social security numbers may also be disclosed to other governmental regulatory agencies and for identification purposes to testing providers and organizations involved in professional regulation. Your social security number will not be released for any other purpose not provided for by law.

PERMIT AFFIDAVIT

I (applicant’s name) ___________________________, an employee of (company name)

_______________________ do hereby declare that I have the ability to obtain the proper

manufacturer’s installation and maintenance manuals and manufacturer’s parts for the

(manufacturer’s makes and model numbers) _____________________________________

pre-engineered fire extinguishing system(s), and I will have them in my possession when

performing all installations and/or maintenance.

I further testify that I will conduct all installations and/or maintenance in complete compliance

with the manufacturer’s installation and maintenance manuals with the exception of obtaining

a manufacturer’s training certificate. I understand that any violation of this affidavit will be

grounds for the revocation of my Class D fire equipment permit.

__________________________________ Applicant __________________________________ Date SWORN AND SUBSCRIBED TO BEFORE ME THIS _____ DAY OF ___________ 20____. _________________________________ NOTARY PUBLIC My commission expires: _____________ NOTE: Current Manufacturers Training Certificates must be on file in the OSFM for a Class “D” Permit.

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VISA/MASTERCARD PAYMENT FORM

To make payment by VISA/MasterCard, please complete the following information and mail or fax to:

Chief of Licensing and Permitting South Carolina Department of Labor, Licensing, & Regulation Division of Fire & Life Safety 141 Monticello Trail Columbia, SC 29203 Fax: 803-896-9806 ___________________________________________________________________________________

Company Name/ Mailing Address Telephone No: ______________________ Fax No: __________________________ __________________________________ Email Address: ____________________ Print name as it appears on credit card Type of card: MasterCard VISA Expiration Date: ___________________ __________________________________ ________________________________ Credit Card Number Authorized Signature

(FORM IS NOT VALID WITHOUT AUTHORIZED SIGNATURE)

Description Fee Amount

Do you need a receipt? YES NO

141 Monticello Trail Columbia, SC 29203 Phone: (803) 896-9800 Fax: (803) 896-9806 www.llronline.com

Office of State Fire Marshal

FOR OFFICE USE ONLY

Category Code (Circle one) BL DL BP MP FM Description ____________________________________________________________________________________________