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APPLICATION FOR SPACE / TENANT INFORMATION Virgin Islands Port Authority Property Management P. O. Box 301707 St. Thomas, VI 00803-1707 (340) 774-1629 (phone) (340) 715-0134 (fax) Application Fee (Non-Refundable) $75.00 (Existing Tenant) $150.00 (New Applicant) (Please make check payable to V. I. Port Authority.) Rev. 12.01.08 APPLICATION CHECKLIST The Virgin Islands Port Authority reserves the right to return incomplete applications or to request additional information and/or documentation regarding this application. _____ V. I. Business License (current) _____ V. I. Certificate of Good Standing (current – dated July 1(FY) or later) (for corporations and tradename users / if new entity, a stamped copy of receipt from Lt. Governor’s Office showing filing of required documents) – ______ Articles of Incorporation, if applicable ______ Insurance Certificate (if new applicant, sample certificate) ______ Application (Signed and Dated) with Certification Page Notarized ______ Application Fee (Please make checks payable to the V. I. Port Authority) If an Airline (Additional Documents) ______ Air Carrier Certificate (issued by Local FAA FS) ______ Operations Certificate (showing FAA Approval of use of tradename, if applicable) ______ Proposed Flight Schedule ______ Insurance Certificate If a Ferry Boat Company / Marine Operations (Additional Documents) ______ U. S. Coast Guard -- Certificate of Inspection & Documentation ______ V. I. Department of Planning & Natural Resources – Proof of Registration ______ Proposed Operating Schedule ______ Insurance Certificate *************************************************************************************************** INSURANCE: In most cases, the Lessee will be required to carry adequate insurance to protect both the Lessee and the Authority against comprehensive public liability and property damage. The terms and limits of the insurance requirements will be based on the risks relative to the Lessee’s operations. (It is suggested that the applicant investigate the cost of such coverage prior to submitting an application for space.) *************************************************************************************************** For additional information about business licenses and/or certificates of good standing, please contact the following agencies: Department of Licensing & Consumer Affairs - Licensing Division - Tel.: (340) 774-3130 Department of Planning & Natural Resources – Tel. (340) 774-3320 Lt. Governor’s Office / Division of Corporation & Tradesmarks - Tel.: (340) 776-8515 FOR VIPA’S USE ONLY: Rev. 12.01.08 VIRGIN ISLANDS PORT AUTHORITY APPLICATION FOR SPACE/ TENANT INFORMATION 1. Applicant/ Business Name _____________________________________________ Physical Address (current) _____________________________________________ _____________________________________________ Mailing Address (if different from above) _____________________________________________ _____________________________________________ Phone:_(______)______________ Fax: _(______)__________________ E-Mail: ______________________ Website: ______________________ 2. Contact Person/ Position: ______________________________________________ Phone: _(_____)__________ Fax: _(_____)_________ E-Mail ______________ 3. V. I. Port Authority Area(s) / Property (-ies) being requested for lease: __________________________________________________________________ __________________________________________________________________ 4. Requested Use(s) of Property: List all Activities or Business Functions to Occur at Premises (Please provide sufficient information to fully describe the activities. Additional information may be attached.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 5. Term (and Option, if applicable) Requested:_______________________________ (Term granted is dependent on current policy and/or proposed investment) If applicant is current lease: _______ New lease _______ Term Extension -- Current Expiration Date _______________________ 6. Name to Appear On Lease: _____________________________________________ (including tradename(s)) ________________________________________________________________ Name of Person/Position Executing the Lease ___________________________________________ VIRGIN ISLANDS PORT AUTHORITY APPLICATION FOR SPACE / TENANT INFORMATION Rev. 12.01.08 7. Type of Business __________________________________________________ ___________________________________________________________________ 8. Business Status (Please indicate which type below and provide supporting documentation / Please check only one.) _____ Individual _____ Partnership _____ Corporation _____ Joint Venture _____ Limited Liability Company (LLC) _____ Government _____ Other: ______________________________ If Incorporated: Date of Incorporation ________________________________ V. I. Corporation In Good Standing _____ Yes ____ No Tradenames (If Any) __________________________________________________ Federal Tax ID Number ________________________________________________ Are you registered to do business in the United States Virgin Islands? _____ Yes _____ No 9. V. I. Business License No.(s) ______________________________________ (Attach copy) ______________________________________ List all other Licenses held ____________________________________________ ____________________________________________ 10. Name Of Principal(s) / Position(s) / Home Address(es) A. _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ B. _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ C. _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ VIRGIN ISLANDS PORT AUTHORITY APPLICATION FOR SPACE / TENANT INFORMATION Rev. 12.01.08 11. Name Of Resident Agent ______________________________________________ Address ________________________________________________________ ________________________________________________________ Phone: _(______)______________ Fax: _(______)_____________ 12. Objectives (Applicant should clearly and concisely indicate what is intended to be accomplished.) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 13. Expected Markets for Product(s) and/or Service(s) (Include information pertaining to expected volume, trends, etc.) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 14. Experience (Describe extent, including duration, of business experience with emphasis on proposed type of business; Detail the experience of management or proposed management personnel.) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 15. Number of Jobs to be Created by This Project ___________________________________________________________________ ___________________________________________________________________ 16. Estimated size of space requested / How much space (i.e., sq. ft., acres, etc.) is required for operations or in accordance with zoning law? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 17. Do you plan to construct or place improvements on the Premises? ____ Yes _____ No VIRGIN ISLANDS PORT AUTHORITY APPLICATION FOR SPACE / TENANT INFORMATION Rev. 12.01.08 18. Describe proposed improvements, type(s) of construction and required utilities and/or amenities -- Attach appropriate drawings and/or maps __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 19. Estimated Costs of Investment: (REQUIRED) Labor $ ____________________ Improvements $ ____________________ ____________________ $ ____________________ ____________________ $ ____________________ Total $ ____________________ 20. Proposed Source(s) Of Financing for Investment ___________________________________________________________________ ___________________________________________________________________ 21. Projected Work Plan and Timetable (included anticipated start and completion dates) ___________________________________________________________________ ___________________________________________________________________ 22. Estimated Gross Income for the first/ next 5 Years of Operation (REQUIRED) Year 1 $ _____________________ Year 2 $ _____________________ Year 3 $ _____________________ Year 4 $ _____________________ Year 5 $ _____________________ 23. Organizations(s) and/or Person(s) Consulted __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ VIRGIN ISLANDS PORT AUTHORITY APPLICATION FOR SPACE / TENANT INFORMATION Rev. 12.01.08 24. Latest Financial Statement (Auditor Certified) / Credit Report Attached ____Yes _____No 25. Business References (REQUIRED) NAME COMPANY CONTACT # A. ________________________________________________________________ B. ________________________________________________________________ C. ________________________________________________________________ 26. Additional Information (pages may be added to further support application) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ UNSIGNED OR INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. ALL INFORMATION SUBMITTED ARE SUBJECT TO BE DISCLOSED TO THE PUBLIC UNDER THE FREEDOM OF INFORMATION ACT OF THE VIRGIN ISLANDS. SUBMITTED BY: SIGNATURE: _____________________________________________________ PRINT NAME: _____________________________________________________ POSITION: _____________________________________________________ DATE: _____________________________________________________ VIRGIN ISLANDS PORT AUTHORITY APPLICATION FOR SPACE / TENANT INFORMATION Rev. 12.01.08 CERTIFICATION BY APPLICANT The undersigned applicant hereby certifies that: It has not intentionally or unintentionally misrepresented or omitted material fact and has made full disclosure on the application and in supporting documentation(s); It has not knowingly engaged the services of any member of the Board of Governors of the Virgin Islands Port Authority, nor any firm, corporation, joint venture, partnership or other entity of which any member, officer or official of the Virgin Islands Port Authority is officer, director, stockholder or partner for the purpose of securing any benefit or benefits from the Virgin Islands Port Authority for the applicant; and further, It has not knowingly paid any money or obligated itself to pay any money or extended benefit to any member, officer or official of the Virgin Islands Port Authority, or any members of their immediate family, or any corporation, joint venture, partnership or other entity of which any member, officer or official of the Virgin Islands Port Authority is an officer, director, stockholder or partner, within the year immediately preceding the execution of this certification. Dated: ________________ By: ________________________________ Title: ________________________________ Sworn to and subscribed before me this _____ day of _______________, 20 ______. __________________________________ Notary Public My Commission Expires: ______________