UVI RTPARK APPLICANT DUE DILIGENCE SUBMITTAL NAME: SOCIAL SECURITY NUMBER: DATE OF BIRTH: ADDRESS: Lift(' .51. ttmes (al OO 49 I te 6 - 2 s sj o ski/ OCR-C2._ PERSONAL INFORMATION 1. Have you been known by any name or names other than the name listed on this application? If so, please list them and the authority and/or jurisdiction date, etc. where the change took place.. I de 2. Of what country are you a citizen? A. Please indicate the following: i. Place oft yth (City, Statelt tcd SI-cAtes roc A tinev-I C mt-i -4- 44 j GN)0,3 `Kn--tic ii. Country of$irth: , A Jot it-poit r Ca_ B. If you are not a citizen of the United States, please indicate: i. Port of entry to the United States: ii. Name and address of sponsor upon your arrival: iii. If you are a natural citizen, provide the following information: a. Petition number: b. Date granted: c. Court: d. City/State of Court: e. Certificate number: BACKGROUND INFORMATION 3. Have you had or do you have any propriety interest in any other enterprise which is or has been a beneficiary under any economic development program in the USVI (including, but not limited to, RTPark and/or EDC)? ©2008 UVI RTPark Corporation Page 1 of 4 EFTA01123580