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Government of the Unites States Virgin Islands Office of the Commissioner — Division of Banking and Insurance #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 TEL-340-774-7166 FAX 340-774-5590 October 1, 2012, RE: Sales Representatives The Office of the Lieutenant Governor, Division of Banking and Insurance (“Division”),approves all sales representatives authorizing and allowing them to sell and issue ambulance service contracts under Chapter 63 of Title 22 of the VI Code. Pursuant to Section 1688, Title 22, Virgin Islands Code, applicants shall register on or before December 31“ of each year, the name and business office address of each sales representative employed by the company, and shall within thirty (30) days after termination of employment, notify the Commissioner of such termination. Any sales representative employed subsequent to the December 31 filing date shall be registered with the Commissioner within thirty (30) days after such employment. An annual fee of $75.00 shall be paid for each sales representative registered with the Commissioner. Sales representatives must comply with the laws of the U.S. Virgin Islands, and other air ambulance service related laws. Violation of said laws may result in the revocation of their individual license as well as the implementation of fines and/or penalties to both the individual and the company. Attached please find the application required for the 2013 renewal period to be completed and submitted by MASA/SKYMED for all representatives who will continue to maintain their Medical Air Ambulance Representative license. Each rep must also provide a current tax clearance letter from the Bureau of Internal Revenue indicating that they are up to date with their filings with that division. I have included an application form from that office which would help speed up the process with that Division. Should you have any questions or concerns, please do not hesitate to contact the Division or myself. I remain, Gail Danet-Joseph Chief of Licensing INSTRUCTIONS FOR FORMS LIC 1 AND LIC 1A Please print (except for the signature). Do not write with a pencil. Prepare this form in duplicate. Have one of the copies stamped for your record. Save this copy for future reference. DO NOT SUBMIT A COPY OF THIS APPLICATION TO LICENSING AND CONSUMER AFFAIRS. This form must be completed in its entirety before a letter certifying tax filing and payment status can be issued. You are required to complete and submit a notarized affidavit (Form LIC 1A) if you have not resided in the Virgin Islands and have not filed your Federal Income Tax Returns for the three years prior to this application with the Bureau, if you have been unemployed for the past three years or if you were attending school. CORPORATIONS AND PARTNERSHIPS - List name, social security number and mailing address for corporate officers or partners. S CORPORATIONS - Also list name, social security number, and mailing address for all shareholders. ALL INCOMEPLETE APPLICATIONS WILL BE REJECTED. Specific Instructions 1. Applicant Name: The applicant can be an individual (self-employed person); a partnership, a corporation, etc. 2. Business Name: The name under which the business is conducted; it may be the same as or different to the applicant’s name (i.e. John Smith (applicant) d/b/a Smith’s Construction (business name)) (d/b/a — doing business as). 3. Business EIN: Employer Identification Number, a 9-digit number issued by the Internal Revenue Service in Philadelphia to partnerships, corporations and self-employed individuals who pay wages to one or more employees. 4. Applicant SSN: Social Security Number, a 9-digit number issued to an individual by the Social Security Administration. Spouse SSN: also a 9-digit number. 5. Type of License: Check one (1) to indicate whether this application is for a new license or a renewal license. 6. Form of Business: Check one (1) to indicate whether the business is organized as a Sole Proprietorship (self-employed), a Corporation (“C” Corporation), a Partnership, or a Subchapter S Corporation (“S” Corporation). 7. Type of Business: Indicate what activity or profession is the source of your sales {i.e. clothing store, taxi). 8. Circle Forms that you use: 1120(C Corporation), 1065(Partnership), 1120S(S Corporation}, 1040(Individual), 941VI & 501VI (Withholding Tax), 720VO & 720b-VI (Gross Receipts Tax), 722VI (Hotel Room Tax). 9. License Expiration Date: Date shown on your business license. 10. & 11. Person Representing the Applicant: If other than the applicant, a partner or a corporate officer, this individual must attach a valid power of attorney (Form 2848) to receive the tax clearance letter. 12. All applications must be signed. 13. Mailing address is essential for proper delivery of tax clearance letter. 14. Physical Address is also required by licensing. Telephone No.: A daytime number is essential.