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: $_________________