USVI Public Records

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5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Government of the United 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 ORIGINAL APPLICATION FOR AMBULANCE SERVICE SALES REPRESENTATIVES 1. NAME OF APPLICANT:
Mr.
Mrs.
Ms.
Miss
Agency Last ________________________ First ________________________ Middle ______________ COMPANY NAME__________________________________________________________________ 2. IDENTIFICATION INFORMATION: EIN NUMBER-AGENCY________________________ S.S.N. Sex: M F Date of Birth: Place of Birth: MM/DD/YYYY City, State ARE YOU A CITIZEN OF THE UNITED STATES YES NO 3. RESIDENCE ADDRESS: (P.O. Box not acceptable) Street ____________________________________________ Apt/Suite # ________________________ City _________________________________ State _____________________ Zip Code _____________ MAILING ADDRESS P.O. Box __________________________________________________________________________ City __________________________________ State ___________________Zip Code ___________ Home Phone No. ( )-_________-______________ Fax Phone No: ( ) - ______ - ____________ Email: Website: Place of work _______________________________________________________________________________________________________ Business Phone No: ( ) - ________ - ___________ Fax Phone No: ( ) - ______ - ____________ 4. Are you now or have you ever used any name other than shown in question one (1)? Yes No (If yes, please explain fully on a separate sheet) 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 5. Check the name of the authorized Air Ambulance Company which you will represent and from which you will receive an Certificate of Registration allowing you to sell and issue air ambulance service contracts under Chapter 63 Title 22 of the Virgin Islands Code.. MASA SKYMED 6. List your occupation (employment) for the past five years to current date: From (MM/YYYY) To (MM/YYYY) Employer Name Address Duties Performed 7. Have you ever had any professional, vocational or business license denied, suspended, revoked or restricted or a fine imposed by any public authority, or withdrawn any application for or surrendered any such license to avoid disciplinary action? Yes No (If yes, please explain fully on a separate sheet) 8. Have you ever been arrested, charged or convicted of a crime? Yes No (If yes, attach a detailed statement, signed by you, of the events which led to the charges including the dates and places. If the matter was heard in court, attach copies Certified by the Court, of the Criminal Complaint and the Sentencing Order showing the final judgment.) 9. Tax Clearance Letter submitted Dated:___________________________ Original Application Fee: $75.00 (Checks payable to Government of the Virgin Islands) APPLICANT’S CERTIFICATION: I certify under penalty of perjury that I have read the foregoing application and know the contents thereof and that each statement therein made is true and correct. I understand that any false statement may subject my application to denial and may subject my license(s) to suspension or revocation. Further, I authorize disclosure to the insurance commissioner of all financial institutions’ records of any fiduciary accounts for the duration of this license. Date _______________________ _______________________________________________________ Signature ________________________________________ Print Name FOR OFFICE USE ONLY Receipt Number: _______________________ Date: __________________ Amount: $_________________