"Address Change Request Form" - South Carolina

Address Change Request Form is a legal document that was released by the South Carolina Department of Labor, Licensing and Regulation - a government authority operating within South Carolina.

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Download "Address Change Request Form" - South Carolina

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SOUTH CAROLINA CONTRACTOR’S LICENSING BOARD
www.llr.state.sc.us/pol/contractors
ADDRESS CHANGE REQUEST
LICENSED NAME
(as it
:
appears on license card)
LICENSE NUMBER(s):
Change/update the following:
Mailing Address
Physical/Street Address*
Phone Number
Fax Number
*NOTE: If you are a “dual qualifier”, the physical/street address of both licenses must
remain the same at all times
(see www.scstatehouse.gov/code/t40c011.php, §40-11-230(C)).
PREVIOUS MAILING ADDRESS:
Address:
City:
State:
Zip:
NEW MAILING ADDRESS:
Address:
City:
State:
Zip:
PREVIOUS PHYSICAL/STREET ADDRESS:
Address:
City:
State:
Zip:
NEW PHYSICAL/STREET ADDRESS*:
Address:
City:
State:
Zip:
*NOTE: If you are a “dual qualifier”, the physical/street address of both licenses must remain the same
at all times (see www.scstatehouse.gov/code/t40c011.php, §40-11-230(C)).
NEW PHONE NUMBER:
NEW FAX NUMBER:
Owner/President/Authorized Representative Name
Owner/President/Authorized Representative Signature
Date
MAIL: PO Box 11329 Columbia SC 29211; FAX: (803) 896-4814; EMAIL: clbhelp@llr.sc.gov
SOUTH CAROLINA CONTRACTOR’S LICENSING BOARD
www.llr.state.sc.us/pol/contractors
ADDRESS CHANGE REQUEST
LICENSED NAME
(as it
:
appears on license card)
LICENSE NUMBER(s):
Change/update the following:
Mailing Address
Physical/Street Address*
Phone Number
Fax Number
*NOTE: If you are a “dual qualifier”, the physical/street address of both licenses must
remain the same at all times
(see www.scstatehouse.gov/code/t40c011.php, §40-11-230(C)).
PREVIOUS MAILING ADDRESS:
Address:
City:
State:
Zip:
NEW MAILING ADDRESS:
Address:
City:
State:
Zip:
PREVIOUS PHYSICAL/STREET ADDRESS:
Address:
City:
State:
Zip:
NEW PHYSICAL/STREET ADDRESS*:
Address:
City:
State:
Zip:
*NOTE: If you are a “dual qualifier”, the physical/street address of both licenses must remain the same
at all times (see www.scstatehouse.gov/code/t40c011.php, §40-11-230(C)).
NEW PHONE NUMBER:
NEW FAX NUMBER:
Owner/President/Authorized Representative Name
Owner/President/Authorized Representative Signature
Date
MAIL: PO Box 11329 Columbia SC 29211; FAX: (803) 896-4814; EMAIL: clbhelp@llr.sc.gov