Request For Renewal Of Registration - Department Of Licensing And Consumer Affairs
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1
2DEPARTMENT OF LIOEN'SING AND OONSUMER AFFAIRS
V.l. BOARD OF AROHITEOTS, ENGINEERS AND LAND SURVEYORS
REQUEST FOR RENEWAL OF REGISTRATION
DArchitect
$130.00
DEngineer
$130.00
OLand SUlveyor
$52.00
DLandscape Architect
$130.00
1.
Full Name
~
_
2.
Mailing Address
_
3.
Physical Address
~
_
4.
6.
Business Telephone (
Name of Employer
) - - - - - -
5.
.
Home Telephone (
) - - - - -
~
_
7.
Employer's Address
_
8,
Has your license ever been revoked or suspended? (
If yes, please explain:
~
) yes
) no
_
9.
Virgin Islands Resident (
) yes
) no
If yes, how long?
_
10,
Have you ever been censured for unprofessional conduct? (
) yes
) no
If yes, please explain:
,
_
11.
Have your license ever been expired for more than one year? (
) yes
) no
If yes, please explain:
_
Signature of License Holder
Permit Number
I,
, being duly sworn, depose and say that I am the person who executed the
(Name of License Holder)
above document and that the matters stated therein are true to my knowledge.
Sworn and subscribed before me this
day of
,20
_
My Commission Expires
_
Notary
Seal
Notary Public's Signature
*This form must be submitted along with your renewal fee, back copy of your last license and your fa vorable tax cleW'unce letter from
the V.1. Bureau of Internal Revenue to the address below,
V.l. Board of Architects, Engineers and Land Surveyors
Department of Licensing and Consumer Affairs
3000 Golden Rock Shopping Center, Suite 9
Christiansted, VI 00820-4311
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