EFTA01107043.pdf

DIVISION OF BANKING & INSURANCE DUE DILIGENCE CONTRACT INVESTIGATOR APPLICATION NAME: SOCIAL SECURITY NUMBER: DATE OF BIRTH: ADDRESS: 1. Have you been known by any name or names other than the name listed on this application? If so, please list them & the authority and /or jurisdiction date etc. where the change took place. 2. Of what country are you a citizen? A. Please indicate the following: 1. Place of birth (City, State): 2. Country of birth: B. If you are not a citizen of the United States, please indicate: 1. Port of entry to the United States: 2. Name and address of sponsor upon your arrival: Page 1 of 4 EFTA01107043  BACKGROUND INFORMATION 3. Have you ever been arrested or charged with any crime or offense in any jurisdiction? Yes No Ifyes, please explain below. 9. Have you ever been adjudicated bankrupt or filed a petition for any type of bankruptcy, insolvency or liquidation under any bankruptcy or insolvency law in any jurisdiction? Yes No Ifyes, please explain below. 10. Please provide Tax Clearance Letter. 11. Please provide Police Clearance Letter. (Police Records Check) 12. Check the appropriate boxes that apply to your experience: oprior local law enforcement ofederal law enforcement experience oregulatory experience oprosecutors, pothers with peace officer status. oaccountants informer non law enforcement regulators Give Brief resume of experience listed above: Page 2 of 4 EFTA01107044  I certify that: I have adequate financial resources and the ability to perform the required services of any due diligence contract I receive from the Division of Banking & Insurance; I can and will comply with reasonably required or proposed delivery and/or performance schedules (taking into consideration all existing business commitments) and certify that I will complete my investigation and present my report to the Division of Banking and Insurance within 15 days of receiving a contract assignment from the Division. I have a satisfactory record of performance and all current business licenses as may be required by U.S. Virgin Islands law. I have not been debarred or suspended by the federal or U.S.V.I. Government for any work I have performed. Dated this day of , 201 (Signature) Subscribed and sworn to before me this day of , 201_. Notary Public SEAL Page 3 of 4 EFTA01107045  RELEASE AUTHORIZATION To all Courts, Probation Departments, Selective Service Boards, Employers, Educational Institutions, Banks, Financial and Other Such Institutions, Credit Agencies, and All Private or Government Agencies, federal, state and local, without exception, both foreign and domestic. On behalf of (Name) , have authorized the Virgin Islands Division of Banking & Insurance or its designee to conduct a full investigation into the background of the said enterprise, its principals, agents and employees. Therefore, you are herby authorized to release any and all information pertaining to the said enterprise, documentary otherwise, as requested by any agent of the Virgin Islands Division of Banking & Insurance or its designees. A photo static copy of this authorization will be considered as effective and valid as the original. (Signature) Subscribed and sworn to before me this day of 201_. Notary Public SEAL Page 4 of 4 EFTA01107046