DIVISION OF REVENUE AND TAXATION

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1 O W L O I I L F I I L L OH H I H L IL IVIIO VU XIO O O W O H H H Business License pplication equirements for cuba iving Instruction and/or our Operator O F F I Business License pplication for cuba iving Instruction and/or our Operation (equired attachments listed on art of the application) ffidavit of ertification and Good tanding (must be notarized) Workers ompensation pplication for learance Updated nnual eport (filed with I egistrar of orporations) opies of assports of orporate Officers, irectors and hareholders Immigration tatus of orporate Officers, irectors and hareholders (non-u) ap of hysical Location of Business Original License(s) to be renewed F: Form: BULI- UB IVIG IUIO $ UB IVIG OU OIO $ age 1 ote: his revision is effective ovember 2015

2 O H O O W Y LIIO ew enewal Business License o. mendment (check below) dditional location hange of location dd B O I I L Business License pplication for cuba iving Instruction and/or our Operator F I I L L. OH H I H L IL O W L IVIIO VU XIO H H O F F I axpayer s I.. o.: Federal mployer I.. o.: 1st Year of Operation: hange of business name equest for duplicate license B. LI IFOIO 1. Form of Business: orporation ole roprietorship artnership Limited Liability ompany Other LI: 2. ailing ddress: el: Fax:. LI() BUI LI FO: mail address: UB IVIG IUIO.B.. (assumed name) UB IVIG OU OIO Island Village If the applicant is a foreign corporation or a non-i resident, please provide the name of the registered agent below. ame: ailing ddress: el:. H HO H FOLLOWIG OU: roof of employment for each employee serving as a scuba diving instructor or tour leader. opy of certification card issued by I, UI, or other certification agency for each instructor, assistant instructor, or dive master employed by the business. ffidavit of certification and good standing completed and signed by each employee to be employed as a scuba diving instructor and/or tour leader. roof of liability insurance sufficient to insure the employee(s) and business against accidental injury of any student and/or customer that may occur during the course of the instruction or scuba diving tour in an amount no less than five hundred thousand dollars ($500,000.00) per incident ote liability insurance must be shown in U.. dollars.. LI LIO I declare under penalty of perjury that the information above and documents attached hereto are true and correct, and that I have complied with all ommonwealth laws, rules and regulations, promulgated pursuant thereto. I understand that any violation of I licensing requirements or the afe iving ct, or any willful misstatement or omission of a material fact on this application, or any documents attached hereto, shall be grounds for denial or revocation of a business license, and shall subject me to the imposition of civil and/or criminal penalties, or both, as allowed by law. eclaration is made on this day of 20 at. rint pplicant s ame ignature itle ate FIIL U OLY he applicant is is not recommended for approval for the issuance of a business license. eviewed by ate pproved by ate ate license issued Business License umber License fee paid $ enalty $ ate paid eceipt o. Form: BULI- age 2 ote: his revision is effective ovember 2015

3 O W L O I I L ffidavit of ertification and Good tanding for cuba iving Instruction and/or our Operator F I I L L OH H I H L IL IVIIO VU XIO O O W O H H H O F F I I,, being duly sworn and on oath do hereby depose and say; 1. hat I, am a resident of, 2. hat I, am a certified. (Indicate level of certification, i.e., instructor, assistant instructor, or dive master and indicate certifying organization). 3. hat I, am employed by (ame of company, corporation, or employer) in the capacity of a (indicate if employed as an instructor or tour leader for scuba diving) 4. ttached hereto is a true and correct copy of my certification, indicating current status. If employed as a scuba diving tour leader: he standard of the certifying organization indicated in item number (2) above does does not permit me to guide scuba divers underwater. y certification is current and has not been revoked or lapsed. ated this day of 20. UBIB WO O before me, this day of 20 OY UBLI Form: BULI- age 3 ote: his revision is effective ovember 2015

4 OOWLH H OH I IL IVIIO VU XIO IL OOWLH H OH I FIIL L Business License pplication Business Location O F F I ap of Business Location (i.e., street name, village, etc...) hysical Location of Business Form: BULI age 3 ote: his revision is effective ovember 2015

5 epartment of ommerce WOK OIO OIIO OOWLH H OH I IL.O. Box 5795 HB, aipan el: (670) /8024 Fax (670) Website: pplication for ertificate of learance lease take notice that pursuant to the I Workers' ompensation Law, as amended, every employer in the ommonwealth is required to secure insurance coverage for employee(s) in case of occupational injury, illness, or death. he law further requires that all applicants for business licenses in the I (whether its an application for a new business or the renewal for an existing business) must obtain a ertificate of learance from the Workers' ompensation ommission before the ecretary of Finance will issue such business license. ame of Business: ddress: ame of pplicant/epresentative:. L K H OI () BLOW. BUI LI LI - W: I am not an employer now. I do, however, understand the requirement of the Workers' ompensation Law. If I hire any employee in the future, I will comply with the requirements as mandated by law, and immediately secure coverage for my employee(s) and will file a ertificate of ompliance within 30 days thereafter. I am an employer or will be hiring personnel within a few days. I am providing a copy of the workers' compensation insurance policy in effect and a ertificate of ompliance (FO W- I 00) as required. I have never been an employer operating under a different name. B. BUI LI LI - WL: I have renewed the workers' compensation insurance coverage. I am providing a copy of the workers' compensation insurance policy in effect and a ertificate of ompliance (FO W-100) as required. I did not or no longer have any personnel employed by the business. ignature of pplicant or epresentative ate aipan Branch: FO W-101 (V 6/96) inian Branch: ota Branch:

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