USVI Public Records

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Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Telephone: 340.714.3522 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov VIRGIN ISLANDS REAL ESTATE COMMISSION APPLICATION FOR REAL ESTATE SALESMAN’S PERMIT NON REFUNDABLE APPLICATION FEE: $50.00 ¨ Temporary Permit & Examination ¨ Examination Only Part I The undersigned, a licensed V.I. Real Estate Broker, declare that I hereby sponsor the herein named for a Real Estate Salesman’s License and that I shall be fully responsible for his professional actions in accordance with the regulations and provisions of Title 27, Chapter 15 of the Virgin Islands Code. Sponsoring Broker’s Signature _________________________ License # ________ Date _________ Print Name ________________________________________ Broker’s Trade Name _______________________ Broker’s Email _____________________________ Broker’s Trade Address _____________________ _________________________________________ Witness’ Signature ___________________________ Witness’ Signature _______________________ Part II 1. Full Name ______________________________________________________________________ First Middle Last 2. Father’s Name __________________________ 3. Mother’s Maiden Name _________________ 4. Have you ever changed your name? ( ) Yes ( ) No If yes, attach certified copy of Court Order authorizing name change. 5. Physical Address _________________________________________________________________ 6. Mailing Address __________________________________________________________________ Email Address ______________________________________ 7. Home Telephone # ( ) _________________ Mobile # ( ) __________________ 8. Date of Birth ____________________________ 9. Place of Birth _________________________ 10. Citizenship _____________________________ 11. Naturalized ( ) Yes ( ) No If you are a non-US citizen or naturalized citizen attach a copy of your green card or naturalization documents. 12. Social Security Number _________________________ 13. Virgin Islands Resident ( ) Yes ( ) No If yes, how long? ________________________ 14. If you answered No to question 13, please list all jurisdictions in which you have lived for the last 5 years. Attach police reports from all jurisdictions listed below. _______________________________________________________________________________ 15. When was VI residence established? ____________ Attached proof of residency (electric bill, lease agreement.) 16. If VI residency is less than 2 years, list previous address: _______________________________________________________________________________ 17. Present business or professional activity ______________________________________________ 18. Have you previously taken the examination for a V.I. Real Estate Salesman’s License? ( ) Yes ( ) No If yes, list the date of the examination(s) and result(s). ________________________________ 19. Have you served in the Armed Forces? ( ) Yes ( ) No Type of discharge _________________ Attach a copy of your discharge papers. 20. If you answered Yes to question 19, give date(s) of service, branch of service, serial number, rate of rank and commendations and/or decorations. _______________________________________________________________________________ _______________________________________________________________________________ 21. Have you ever been discharged or have you ever resigned from a position because of alleged misconduct or misappropriation of funds? ( ) Yes ( ) No If yes, provide date and full details _______________________________________________________________________________ _______________________________________________________________________________ 22. Have you ever been convicted of a felony? ( ) Yes ( ) No If yes, please explain: _______________________________________________________________________________ _____________________________________________________________________________ 23. List any additional information you feel may be pertinent to this application. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 24. PROFESSIONAL REFERENCES Name Address Telephone Number 1. 2. 3. 25. CHARACTER REFERENCES Name Address Telephone Number 1. 2. Part IV EDUCATION (Please list in chronological order, beginning with the most recent) 26. COLLEGE Name and Address of Institution Attendance From To Graduation Date Degree Received 1. 2. 3. Part III REFERENCES: VI Real Estate Commission members and relatives of the applicant may not be listed as references. At least two (2) individuals listed as references must be residents of the Virgin Islands for the past five (5) years. Provide letters from all references listed on the application. 27. HIGH SCHOOL Name and Address of Institution Attendance From To Graduation Date Degree Received 1. 2. 3. ALL INFORMATION MUST BE VERIFIABLE. ANY FALSE INFORMATION MAY BE REASON FOR DENIAL OF APPLICATION. Part IV Applicant Name______________________ AFFIDAVIT (Must be completed by all applicants) 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 information that might affect this application; and that I have read and understand this affidavit. _____________________________ Applicant's Signature Witness my hand and official seal this ______ day of ____________________, 20 _____. ____________________________ {SEAL} Notary Public My commission expires:_______________ Do not write below this line - FOR OFFICIAL USE ONLY BOARD DISPOSITION: