FORM - RACA12 
THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF CORPORATIONS AND TRADEMARKS 
RESIDENT AGENT FORM 
FOR SERVICE OF PROCESS 
This writing witnesseth that I, the undersigned _________________________________________________, 
having been designated by _______________________________________________________________, 
as resident agent of said company, upon whom service of process may be made in all suits 
arising against said company in the Courts of the United States Virgin Islands, do hereby consent 
to act as such agent and that service of process may be made upon me in accordance with 
Titles 11 (Chapter 21), 13, and 26 of the Virgin Islands Code. 
IN 
WITNESS 
WHEREOF, 
I 
have 
hereunto 
set 
my 
signature 
this 
_______ 
day 
of 
___________________________________________________, _______________. 
________________________________________________ 
SIGNATURE OF RESIDENT AGENT 
DAYTIME CONTACT NUMBER 
PHYSICAL ADDRESS 
MAILING ADDRESS 
EMAIL ADDRESS 
NOTARY ACKNOWLEDGEMENT
              (ONLY IN USVI) 
Subscribed and sworn to before me this ________ day of ________________________________, ___________ at 
___________________________________________________. 
________________________________________________ 
Notary Public 
_______________________________________________ 
My Commission Expires 
I DECLARE, UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE UNITED STATES VIRGIN ISLANDS, THAT ALL STATEMENTS CONTAINED IN THIS APPLICATION, AND ANY 
ACCOMPANYING DOCUMENTS, ARE TRUE AND CORRECT, WITH FULL KNOWLEDGE THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE SUBJECT TO INVESTIGATION 
AND THAT ANY FALSE OR DISHONEST ANSWER TO ANY QUESTION MAY BE GROUNDS FOR DENIAL OR SUBSEQUENT REVOCATION OF REGISTRATION. 
Comment [t1]: Name of the Resident Agent. 
Comment [t2]: Name of the entity for which the 
Resident Agent will be working. 
Comment [t3]: Day, month, year of document 
execution. 
Comment [t4]: Daytime contact number, USVI 
physical, USVI mailing, and email addresses of the 
Resident Agent.