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. 00802-6487 TEL (340)774-7166 FAX (340)774-5570 AMBULANCE SERVICE APPLICATION Original/Renewal Type of Company: □ Domestic □ Foreign □ Alien Lines of business: □ Ambulance Service □ Other _________________________ 1. NAME OF ORGANIZATION:________________________________________________________ (Please indicate Companies full legal name) E.I.N. _______________________________________ E-mail: _____________________ Website: _______________________ 2. PRINCIPAL BUSINESS ADDRESS: □ Address Change from last renewal? Physical: Street ________________________________________ Apt/Suite # ______________ City ____________________________ State _______________________ Zip Code __________ Business Phone Number: _____________ Fax Phone Number: _________________ Mailing: P.O. Box/Street ____________________________________ Apt/Suite # _________ City ____________________________ State _______________________ Zip Code __________ Business Phone Number: _______________ Fax Phone Number: ___________________________ 3. Capital:___________________ Surplus:_____________________ as of Date ________ 4. Name of Institution were Statutory Deposit is being held _________________________ Account #____________________ Type: □ C.D. □ Bond □ Letter of Credit □ Other _________________________ 5. Contact Person for Premium Tax Filings Name:________________________ Title: __________________ E-mail: _____________________ Mailing: P.O. Box/Street ____________________________________ Apt/Suite # _________ 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 Page 2 2 City ____________________________ State _______________________ Zip Code __________ 6. Contact Person for Annual Statement and Audited Financial Report Filing Name:________________________ Title: __________________ E-mail: _____________________ Mailing: P.O. Box/Street ____________________________________ Apt/Suite # _________ City ____________________________ State _______________________ Zip Code __________ 7. Contact Person for Licensure and Related filings Name:________________________ Title: __________________ E-mail: _____________________ Mailing: P.O. Box/Street ____________________________________ Apt/Suite # _________ City ____________________________ State _______________________ Zip Code __________ 8. Contact Person for Policy Forms Name:________________________ Title: __________________ E-mail: _____________________ Mailing: P.O. Box/Street ____________________________________ Apt/Suite # _________ City ____________________________ State _______________________ Zip Code __________ 9. Contact Person for Consumer Complaints Name:________________________ Title: __________________ E-mail: _____________________ Mailing: P.O. Box/Street ____________________________________ Apt/Suite # _________ City ____________________________ State _______________________ Zip Code __________ 10. Contact Person for Company’s Statutory Deposit Name:________________________ Title: __________________ E-mail: _____________________ Mailing: P.O. Box/Street ____________________________________ Apt/Suite # _________ City ____________________________ State _______________________ Zip Code __________ 11. Authorized Signatories to Appoint and Terminate Sales Representatives in the U.S. Virgin Islands: Name (Print) Signature ________________________________ ______________________________ ________________________________ ______________________________ 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 Page 3 3 ________________________________ ______________________________ 12. List Name of Sales Representatives and/or Agencies currently representing Company in the U.S. Virgin Islands for marketing of products. (Attach additional sheet(s) if necessary) ________________________________ _________________________________ ________________________________ _________________________________ ________________________________ _________________________________ ________________________________ _________________________________ ________________________________ _________________________________ IMPORTANT NOTICE: The Company must promptly notify the Division of Banking and Insurance of any changes in the information reported on this application. PERSON COMPLETING THIS APPLICATION: Print Name ___________________ Title ___________________ Date_____________ Signature ___________________ Relationship to Company ___________________ FOR OFFICE USE ONLY Receipt Number: _______________________ Date: ______________ Amount: ________________ 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. 00802-6487 TEL (340)774-7166 FAX (340)774-5570 APPOINTMENT OF LIEUTENANT GOVERNOR AS AGENT FOR SERVICE OF PROCESS ~ ~ײ KNOW ALL MEN BY THESE PRESENTS That the __________________________________________________________________________ a foreign corporation, incorporated and organized under the laws of the State of_________________ ______________________________________, now authorized or having applied for authority to do a pawnbroker business in the Virgin Islands, hereby appoints the Lieutenant Governor of said Virgin Islands and his successors in office, its true and lawfully ATTORNEY, in and for the Virgin Islands, upon whom all lawful process against said pawnbroker may be served in any action or proceeding in the Virgin Islands, subject to and in accordance with all provisions of the Pawnbroker Laws of said Virgin Islands in force at the time of such service, which shall not be terminated so long as there are in effect any contracts, or liabilities or duties arising out of contracts, which were issued or delivered by such pawnbroker in the said Virgin Islands. IN WITNESS WHEREOF, The said________________________ ___________________________________ in accordance with the resolution of its Board of Directors duly passed on the _____ day of ________________, 20 ____, a copy of which is filed herewith, has to these presents affixed its corporate seal, and caused the same to be subscribed and attested by its President and Secretary, at the city of________________________________ in the State of __________________________________________ on the ___________ day of ____________________, 20 ________ ______________________________________________________ By _____________________________________, President ATTEST: _________________________________, Secretary STATE OF ________________________________ County of ____________________, To Wit: 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 Page 5 5 I, _______________________________________, a Notary Public in and for the County and State aforesaid, do certify that _____________________________ personally appeared before me in my said county, and being by me duly sworn, did depose and say, that they are respectively the President and the Secretary of the Corporation described in writing above, bearing date the ____________ day of ______________________, 20__________, authorized by said corporation to execute and acknowledge deeds and other writings of said Corporation, and that the seal affixed to said writing is the Corporate seal of said Corporation and that said writing was signed by them in behalf of said Corporation by its authority duly given. And the said _________________________ acknowledged the said writing to be the act and deed of said Corporation. Given under my hand and official seal this ____ day of ______________, 20 ____. ____________________________________ Notary Public Notary Seal: 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. 00802-6487 TEL (340)774-7166 FAX (340)774-5570 CONTACT PERSON(S) FOR ________________________________________ (Please indicate company’s name) 1. Company’s President:__________________________________________ Mailing Address: ______________________________________________ ______________________________________________ Telephone No._______________________ Fax No.___________________ E-Mail_____________________________ 2. Contact Person – Licensure and related filings Name/Title: _____________________________________________________ Mailing Address: _________________________________________________ _________________________________________________ Telephone No.____________________Fax No._________________________ E-Mail__________________________ 3. Contact Person – Consumer Complaints Name/Title: _____________________________________________________ Mailing Address: _________________________________________________ _________________________________________________ Telephone No.____________________Fax No._________________________ E-Mail__________________________ 4. Contact Person – Company’s Statutory Deposit Name/Title: _____________________________________________________ Mailing Address: _________________________________________________ _________________________________________________ Telephone No.____________________Fax No._________________________ E-Mail__________________________ 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. 00802-6487 TEL (340)774-7166 FAX (340)774-5570 Applicant Name (Company) ______________________________ NAIC No. __________________ FEIN: __________________ BIOGRAPHICAL AFFIDAVIT To the extent permitted by law, this affidavit will be kept confidential by the territory insurance regulatory authority. (Print or Type) Full Name, Address and telephone number of the present or proposed entity under which this biographical statement is being required (Do Not Use Group Names). ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________ In connection with the above-named entity, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) IF ANSWER IS “NO” OR “NONE,” SO STATE. 1. Affiant’s Full name (Initials Not Acceptable). ________________________________________________ 2. a. Are you a citizen of the United States? b. Are you a citizen of any other country, if so, what country? ________________________________ 3. Affiant’s Occupation or Profession. ______________________________________________________ 4. Affiant’s business address. ______________________________________________________________ Business telephone. __________________________________________________________________ 5. Education and Training: College/University City/State Dates Attended (MM/YY) Degree Obtained ____________________________________________________________________________________________ Graduates Studies: College/University City/State Dates Attended (MM/YY) Degree Obtained ________________________________________________________________________________________________ Other Training: Name City/State Dates Attended (MM/YY) Degree/Certification Obtained _____________________________________________________________________________________________ (Note: If affiant attended a foreign school, please provide full address and telephone number of the college/university. If applicable, prove the foreign student Identification Number in the space provided in the Biographical Affidavit Supplemental Information.) 6. List of memberships in professional societies and associations Name of Contact Name Address of Telephone Number Society/Association Society/Association of Society/Association ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________________________ 7. Present or proposed position with the applicant entity. __________________________________________ 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 Page 8 8 ___________________________________________________________________________________________________ 8. List complete employment record for the past twenty (20) years, whether compensated or otherwise (up to and including present jobs, positions, partnerships, owner of an entity, administrator, manager, operator, directorates or officerships). Please list the most recent first. Attach additional pages if the space provided is insufficient. It is only necessary to provide telephone numbers and supervisory information for the past ten (10) years. Beginning/Ending Dates (MM/YY) ________-_________ Employer’s Name __________________________________________________ Address__________________________________ City ___________________________ State/Province_____________ Country _______Zip Code______________Phone _________________ Offices /Positions Held __________________ Supervisor/Contact _________ _______________________________________________________________________ Beginning/Ending Dates (MM/YY) ________-_________ Employer’s Name __________________________________________________ Address__________________________________ City ___________________________ State/Province_____________ Country _______Zip Code______________Phone _________________ Offices /Positions Held __________________ Supervisor/Contact _________ _______________________________________________________________________ Beginning/Ending Dates (MM/YY) ________-_________ Employer’s Name __________________________________________________ Address__________________________________ City ___________________________ State/Province_____________ Country _______Zip Code______________Phone _________________ Offices /Positions Held __________________ Supervisor/Contact _________ _______________________________________________________________________ Beginning/Ending Dates (MM/YY) ________-_________ Employer’s Name __________________________________________________ Address__________________________________ City ___________________________ State/Province_____________ Country _______Zip Code______________Phone _________________ Offices /Positions Held __________________ Supervisor/Contact _________ _______________________________________________________________________ 9. a. Have you ever been in a position which required a fidelity bond? ____________ If any claims were made on the bond, give details. ____________________________________________________________________ ________________________________________________________________________________________________ b. Have you ever been denied an individual or position schedule fidelity bond, or had a bond canceled or revoked? If yes, give details. ___________________________________________________________________ ________________________________________________________________________________________________ 10. List any professional, occupational and vocational licenses (including licenses to sell securities) issued by any public or governmental licensing agency or regulatory authority or licensing authority that you presently hold or have held in the past. For any non-insurance regulatory issuer, identify and provide the name, address and telephone number of the licensing authority or regulatory body having jurisdiction over the license(s) issued. If your professional license number is your Social Security Number (SSN) or embeds your SSN or any sequence of more than five numbers that are reasonably identifiable as your SSN for that portion of the professional license number that is represented by your SSN. (For example, “SSN”, “12-SSN-345” or “1234-SSN” (last 6 digits)). Attach additional pages if the space provided is insufficient. _____________________________________________________________________________________________ Organization/Issuer of License ___________________________ Address__________________________________________ License Type _____________________ License # ________________________ Date Issued (MM/YY) _____________ Date Expired (MM/YY) __________________ Reason for Termination _______________________________________ Non-insurance Regulatory Phone Number (if known)_____________________________________________________ Organization/Issuer of License __________________________Address _____________________________________ City _______________ State/Province ___________ Country ______________ Postal Code _____________________ 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 Page 9 9 License Type ____________________ License # __________________ Date Issued (MM/YY) _____________________ Date Expired (MM/YY) ______________________ Reason for termination ___________________________________ Non-insurance Regulatory Phone Number (if known) _____________________________________________________ 11. In responding to the following, if the record has been sealed or expunged, and the affiant has personally verified that the record was sealed or expunged, an affiant may respond “no” to the question. Have you ever: a. Been refused an occupational, professional or vocational license or permit by any regulatory authority, or any public administrative, or governmental licensing agency? ___________________________________________________________________________ b. Had any occupational, professional, or vocational license or permit you hold or have held, been subject to any judicial, administrative, regulatory, or disciplinary action? _____________________________________________________________________________ c. Been placed on probation or had a fine levied against you or your occupational, professional, or vocational license or permit in any judicial, administrative, regulatory, or disciplinary action? ___________________________________________________________________________ d. Been charged with, or indicted for, any criminal offenses(s) other than civil traffic offenses? _________________ e. Pled guilty, or nolo contendere, or been convicted of, any criminal offense(s) other than civil traffic offenses? __________________________________________________________________________ f. Had adjudication of guilt withheld, had a sentence imposed or suspended, has pronouncement of a sentence suspended, or been pardoned, fined or placed on probation, for any criminal offenses(s) other than civil traffic offenses? ________________________________________ ___________________________________________________________________________ g. Been subject to a cease and desist letter or order, or enjoined, either temporarily or permanently, in any judicial, administrative, regulatory, or disciplinary action, from violating any federal, state law or law of another country regulating the business of insurance, securities or banking or from carrying out any particular practice or practices in the course of the business of insurance, securities or banking? __________________________________________________ __________________________________________________________________________ h. Been, within the last ten (10) years, a party to any civil action involving dishonesty, breach of trust, or a financial dispute? ______________________________________________________ ___________________________________________________________________________ I. Had a finding made by the Comptroller of any state or the Federal Government that you have violated any provisions of small loan laws, banking or trust company laws, or credit union laws or that you have violated any rule or regulation lawfully made be the Comptroller of any state or the Federal Government? ______________________________________________________ j. Had a lien or foreclosure action filed against you or any entity while you were associated with that entity? _________________________________________________________________ If the response to any question above is answered “Yes”, please provide details including dates, locations, disposition etc. Attach a copy of the complaint and filed adjudication or settlement as appropriate. __________________________________________________________________________________ ________________________________________________________________________________ 12. List any entity subject to regulation by an insurance regulatory authority that you control directly or indirectly. The term “control” (including the terms “controlling,” “controlled by” and “under common control with”) means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power 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 Page 10 10 is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing, ten percent (10%) or more of the voting securities of any other person. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ If any of the stock is pledged or hypothecated in any way, give details._________________________________________________________________________ _________________________________________________________________________________ 13. Do [Will] you or members of your immediate family individually or cumulatively subscribe to or own, beneficially or of record, 10% or more of the outstanding shares of stock of any entity subject to regulation by an insurance regulatory authority, or its affiliates? An “affiliate” of, or person “affiliated” with, a specific person, is a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified. If the answer is “Yes”, please identify the company or companies in which the cumulative stock holdings represent 10% or more of the outstanding voting securities. ____________________________________________________________________________________ ____________________________________________________________________________________ If any of the share of stock are pledged or hypothecated in any way, give details. ____________________________________________________________________________________ ____________________________________________________________________________________ 14. Have you ever been adjudged as bankrupt?____________ If yes, provide details _________________ _________________________________________________________________________________ 15. To you knowledge has any company or entity for which you were an officer of director, trustee, investment committee member, key management employee or controlling stockholder, had any of the following events occur while you served in such capacity? If yes, please indicate and give details. When responding to questions (b) and (c) affiant should also include any events within twelve (12) months after his or her departure from the entity. a. Been refused a permit license, or certificate of authority by any regulatory authority, or Governmental licensing agency? _________________________________________________ b. Had its permit, license, or certificate of authority suspended, revoked, canceled, non-renewed, or subjected to any judicial, administrative, regulatory, or disciplinary action (including rehabilitation, liquidation, receivership, conservatorship, federal bankruptcy proceeding, state insolvency, supervision or any other similar proceeding)? _____________________________________________________________________________ c. Been placed on probation or had a fine levied against it or against its permit, license or certificate of authority in any civil, criminal, administrative, regulatory, or disciplinary action? ___________________________________________________________________________ Note: If an affiant has any doubt about the accuracy of an answer, the question should be answered in the positive and an explanation provided. Dated and signed this ____ day of ______________________________, 20__________ at _______________________________ I hereby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief. ______________________________________ (Signature of Affiant) Territory of _____________________________ District of____________________ 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 Page 11 11 The foregoing instrument was acknowledged before me this ___________ day of _____________________, 20_______ By ______________________________, and; □ who is personally known to me , or □ who produced the following identification:___________________________ (SEAL) ____________________________________ Notary Public _____________________________________ Printed Notary Name _____________________________________ My Commission Expires 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 Page 12 12 BIOGRAPHICAL AFFIDAVIT Supplemental Personal Information (Print or Type) To the extent permitted by law, this affidavit will be kept confidential by the state insurance regulatory authority. Full Name, Address, and telephone number of the present or proposed entity under which this biographical statement is being required (Do Not Use Group Names). ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 1. Affiant’s Full Name (Initials Not Acceptable)._______________________________________________ 2. Have you ever used any other name including nickname, maiden name or aliases? _______ If yes, give the reason if any, if none indicate such, and provide the full name(s) and date(s) used. Beginning/Ending Name(s) Reason (If None, indicated such) Date(s) Used (MM/YY) ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ ________-__________ ___________________ __________________________________ Note: Dates provided in response to this question may be approximate. Parties using this form understand that there could be an overlap of dates when transitioning from one name to another. 3. Affiant’s Social Security Number __________________________________________________________ 4. Government Identification Number if not a U.S. Citizen___________________________________________ 5. Foreign Student ID # (if applicable)_________________________________________________________ 6. Date of Birth: (MM/DD/YY) ________________ Place of Birth: City ________________________________ State/Province ___________________________ Country _______________________________________ 7. Name of Affiant’s Spouse (if applicable) _____________________________________________________ 8. List your residences for the last ten (10) years starting with your current address, giving: Beginning/Ending Dates State/ (MM/YY) Address City province Country Zip code ________________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________________________ ___________________________________________________________________________________________________ __ Notes: Dates provided in response to this question may be approximate, except for current address. Parties using this form understand that there could be an overlap of dates when transitioning from one address to another. 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 Page 13 13 Dated and signed this ____ day of ______________________________, 20__________ at _______________________________ I hereby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief. ______________________________________ (Signature of Affiant) Territory of _____________________________ District of____________________ The foregoing instrument was acknowledged before me this ___________ day of _____________________, 20_______ By ______________________________, and; □ who is personally known to me , or □ who produced the following identification:___________________________ (SEAL) ____________________________________ Notary Public _____________________________________ Printed Notary Name _____________________________________ My Commission Expires 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 Page 14 14 DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (All states except California, Minnesota and Oklahoma) This Disclosure and Authorization is provided to you in connection with pending or future application(s) of __________________________ (“Company”) for licensure or a permit to organize (“Application”) with a department of insurance in one or more states within the United States. Company desires to procure a consumer or investigative consumer report (or both) (“Background Reports”) regarding your background for review by a department of insurance in any state where Company pursues an Application during the term of your functioning as, or seeking to function as, an officer, member of the board of directors or other management representative (“Affiant”) of Company or of any business entities affiliated with Company (“Term of Affiliation”) for which a Background Report is required by a department of insurance reviewing any Application. Background Reports requested pursuant to your authorization below may contain information bearing on your character, general reputation, personal characteristics mode of living and credit standing. The purpose of such Background Reports will be to evaluate the Application and your background as it pertains thereto. To the extent required by law, the background Reports procured under this Disclosure and Authorization will be maintained as confidential. You may obtain copies of any Background Reports about you from the consumer reporting agency (“CRA”) that produces them. You may also request more information about the nature and scope of such reports by submitting a written request to Company. To obtain contact information regarding CRA or to submit a written request for more information, contact________________________________________. Attached for your information is a “Summary of Your Rights Under the Fair Credit Reporting Act”) AUTHORIZATION: I am currently an Affiant of Company as defined above. I have read and understand the above Disclosure and by my signature below, I consent to the release of Background Reports to a department of insurance in any state where Company files or intends to file an Application, and to the Company, for purposes of investigating and reviewing such Application and my status as an Affiant. I authorize all third parties who are asked to provide information concerning me to cooperate fully by providing the requested information to CRA retained by Company for purposes of the foregoing Background Reports, except records that have been erased or expunged in accordance with law. I understand that I may revoke this authorization at any time by delivering a written revocation to Company and that Company will, in that event, forward such revocation promptly to any CRA that either prepared or is preparing Background Reports under this Disclosure and Authorization. This Authorization shall remain in full force and effect until the earlier of (i) the expiration of the term of Affiliation, (ii) written revocation as described above, or (iii) twelve (12) months following the date of my signature below. A true copy of this Disclosure and Authorization shall be valid and have the same force and effect as the signed original. (Printed Full Name and Residence Address) _______________________________________ ____________________________________ (Signature) (Date) Territory of _____________________________ District of____________________ The foregoing instrument was acknowledged before me this ___________ day of _____________________, 20_______ By ______________________________, and; 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 Page 15 15 □ who is personally known to me , or □ who produced the following identification:___________________________ (SEAL) ____________________________________ Notary Public _____________________________________ Printed Notary Name _____________________________________ My Commission Expires