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□ Real Estate Broker's Examination D Attorney Attach 3 2x2 photo of applicant here The non-refundable application fee of$300.00 must be submitted with the application to include background check. (S50.00 Application Fee and $250.00 initial deposit for background check) Attorneys licensed to practice in the Virgin Island are exempt from the examination and background check. Part I 1. 2. 4. 5. 6. 7. 9. 11. 13. 14. 15. 16. Full Name Father's Name Physical Address Mailing Address E-Mail Address Business Telephone ( ) Birth Date Citizenship Social Security Number Virgin Islands Resident Dyes Previous Address Present Business Activity 0 no 3. Mother's Maiden Name ______ _ 8. Home Telephone ( )_____ _ 10. Birth Place. ___________ _ 12. Naturalized: □ yes O no 13a. Email: If yes, ho\v long? _________ _ Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center 3000 Estate Golden Rock, Suite 9 St. Croix, VI 00820-4311 Administrative Complex “The Battery” St. John, VI 00830 Property & Procurement Building 8201 Subbase, Suite 1 St. Thomas, VI 00802-5826 Telephone: 340.773.2226 Facsimile: 340.773.6982 Telephone: 340.693.8036 Facsimile: 340.776.6989 Telephone: 340.774.3130 Facsimile: 340.776.8303 VIRGIN ISLANDS REAL ESTATE COMMISSION APPLICATOIN FOR REAL ESTATE BROKER'S LICENSE NON REFUNDABLE APPLICATION FEE: $300.00 17. Have you ever been convicted of a felony? □ y es D no If y es, p lease explain: __________________________ _ 18. Has y our license ever been revoked? Dyes O no If yes, please explain: ___________________________ _ 19. Have you ever been censured for unprofessional conduct? O yes D no If y es, please explain: ___________________________ _ 20. Have y ou ever served in the armed forces? Dyes □ no If y es, give dates of active service, branch of service, serial number, rate of rank, commendations or decorations, if any, ty pe of dischar g e: ______________________ _ 21. Have y ou ever been dischar g ed or have you ever resigned from a position because of alleged misconduct or misap p ro p riation of funds? 0 yes D no 22. In Which states are you now registered as a Real Estate Sales p erson or Broker? Submit co p ies of each re 0istration listed ,,., ) State Registration or License # Title of License Expiration Date -- 23. Have you previously taken the examination for a Vir g in Islands Real Estate Broker's License? 0 y es O no If y es, g ive date of examination and examination results 24. Indicate exact location of "Fixed Office" if the re q uested license is granted. _______ _ 25. Trade Name of Business __________________________ _ Part II 26. REFERENCES: At least three 3 of the individuals listed as references must be residents of the Virgin Islands for the past 5 years. Relatives and Commission Members may not be listed as references. Name Address Telephone Number 1. . 2. 3. 4. 5. Part III 27. ( : EDUCATION Pl ease )' 1st m c ono og1ca or er, egrnnmg wit t e most recent. hr . I d b . . h h Name of School/University Attendance Dates Graduation Date Certificate/Degree/Diploma Received 8 2 EXPERIE CE N : P ease list in c ronolo_g1ca order, bee.innine with t e most recent. h . I h Employer's Name and Address Employment Dates Job Title and Description of Duties All information must be verifiable. Any false information may be cause for denial of license. Part IV AFFIDAVIT (Must be completed by all applicants) 29. State of ___________ _ Territory of _________ _ Country of __________ _ I, __________________ , being duly sworn, depose and say that I am the person who executed the foregoing instrument; that I have read the same and know the contents thereof; that the matters stated therein are true to my knowledge; that I have not suppressed any infonnation that might affect this application; and that I have read and understand this affidavit. Applicant's Signature Sworn and Subscribed before me this ____ day of _________ , 20 . ___ _ Notary Public My Commission expires on _____ _ Do not write below this line: COI\1MISSION DISPOSITION: APPROVED 0 DISAPPROVED 0 Date:. __________ _ Signature, Chairman of the Commission Member Member l\'lember Member Member Member , ,nu,, ll·t GO VGҹN,\ffNT Of I II[ VIRGIN 1.-;1 ANIJҺ Of TIIE llNI flD һ r A rr.s VIRGIN ISI.ANns Rl/R[AU or IN'TFRNt\l. REVENUE t\PPI.ICA flON FOR TAX fll.lNG .ҼND PAYMENTSTA"flJS RCPOHT·LICENSING I ltt' OPJ•lic.ml itlt11lifit•il bt'iow l1ad1y rt•11111•s/s ,1 lt'llt•r certifying his or /,er /a:t fili11g ""'' ,,,,y111n1t st11t11s for tltt' 1•11rpose of n•ceit•iug ,, llt'll' or r,·11t'11•11l lici•11se /mm 1/u• IJ1•1111rlm1•n/ of Lin•t1si11g ,1111/ Co11.su111,•r Aff,11rs p11rs11,111t lo St'cli,m 101 of Act 50b0, codified ,rs Title 27, Section 304, S11bclmptt>r (j), Virgin lslmrds Cu.le. n,e cr11plinmt ,111l/wri:t>s tl,e Vir.'{itt l!-lmr,ls B11reau uf lutenwl Rromue to disclose ,my t,1xpr1yt•r i11/11m111tio11 r,•lntl'd lo /Iris 11pplicatiot1 to lire Dt•1mrlmenl of Lice,isiug ,rnd Co11s1w1t•r Aff,1irs, who "'"Y 111,1kt' . .;11cf1 /11rt/1er disclosures 11s ,rre 11eces!>11ry to n1rry out lite n'1Jt1ireme11ts of Act 5060. l. RUSINF.55 ,'\lt\ME: 2. BUS/N£55 £IN: _____ _ J. O'.VNERS SSN: ______________ SPOUSE SSN : _______________ _ PLEAS£ INDICATE: ____ NEW LICENSE _RENEWAL .'>. ___ S£Lf.£AIPLOYED ___ CORPORATION ___ PARTNERSIIJP ___ I.LC ___ lLP 6. DO YOU flAVE E j\lPLOYEES? __________________________ _ 7. PLEASE CIRCLE FORMS THAT YOU USE: (10"10/8689,1065, 1120,941 VI, 7l0Vl,720BVl,722 VI, OTH[R(Iist, __ _ 8. DA ·rE BUSIN[SS STAR rED: _________ LICENSE t:XPlRA llON DATE: ______ _ 9. PERSON REPRESENTING APPLICANT: ____ ·-------- 10. POSITION OF REl'RESEN fA flVE: ____ 11. SIGN:\ l"URE: 12. ,\1:\/LINC ADDRESS: lJ. l'IIYSIC\L ADDRESS: 1-l. D.-\ IE: fELEl'IIONf: --------- ----- lffl'I.Y /0. 11/JIJI /-ҽf.\11. 111<>,\U.S, :-,f_ 11/0,\I,\\ \'/R(;/,'\I l'.'>l.t\,V()S IJO.'iO:!. CJR IOOS ,_.,(,\If l>I \,\/()\JI), I'/ or ill, CIIRhrtAN'.'tl/ IJ, iw,;1.v J<;f.\.VIJ<; tl().'Ҿ2.ll- l-12/ Form Lie lA Affidavit United States Virgin Islands S t.. Croix, St. Thomas, St. John SSN: _______ _ !, . _______________ after first being duly swam, hereby depose and say: 1. That I am a resident o f_ ___________________ _ 2. That during the period from _________ to _______ I have Or been residing in __________________ and haue filed my Federal Income Tax. Returns wµh and pa,id any tax.es due to the United States Federal Government at the Internal lĔeverwe Service Office in and t,:; the State o f ________ _ 3. That during the period from _________ to _________ _ I have been residing in __________________ and I was unemployed or did not have sufficient income to file an Income Tax Return (mark out the one that doĕs not apply.) If I was a.full or part-time student, I attended ______ Ė------------- Signature Subscribed and Swam before me on this _____ day of _______ _ Notary Public 'I REQUIREMENTS FOR LICENSURE PLEASE READ CAREFULLY AND SIGN LICENSING REQUIREMENTS: l. Applicant is required lo pay a non-refundable application fee of $300.00. 2. Applicant must be at least 18 years of age and a resident of the Virgin Islands al least 30 days immediately prior to submission of application. 3. The fol lowing documents must accompany the application. 1. Proof that applicant has been licensed as a Real Estate Salesperson for two (2) consecutive years or is a licensed attorney admitted to practice in the U.S. Virgin Islands. I 2. Certificate of Good Standing from the Territorial or District Court of the Virgin Islands. (Attorneys only) 3. A current favorable tax clearance letter from the V.1. Bureau of Internal Revenue. 4. Copy of applicant's social security card. 5. Three (3) passport size photographs of the applicant. PLEASE NOTE: *If you were born in a foreign country, you are required to give the date of naturalization or date when permanent resident status was established. Attach a certified copy of documentation for inspection with this application. *Upon successful completion of the real estate broker's examination, applicants will be required to pay the license fee for permanent licensurc in the Virgin Islands. I HA VE READ THE ABOVE AND UNDERSTAND THE CONTENT OF SAME. Applicant's Signature Date