Government of the Virgin Islands 
                                                                                               of the United States 
 
 
 
 
Department of Licensing and Consumer Affairs 
 
 
 
 
 
Division Consumer Protection Services 
 
 
(  ) Convenience Store (  ) Small Store (  ) Gas Station w/ Deli (  ) Hardware Store (  ) Pharmacy 
 
 
 
 
 
 
 
 
 
 
ITEM 
BRAND NAME 
UPC NO. 
SIZE 
PRICE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
WITH A CHECK MARK, KINDLY INDICATE STORE CATEGORY, THANK YOU 
Date: ______________________________ 
Name of Establishment: ______________________________________________________________ 
Physical Address: ___________________________________________________________________ 
Mailing Address: ____________________________________________________________________ 
License Number: __________________________   Expiration Date: __________________________ 
Contact Person: ___________________________ Telephone: _______________________________ 
BUSIINESS NAME:  ___________________________________ 
ITEM 
BRAND NAME 
UPC NO. 
SIZE 
PRICE