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Citizenship By Investment
APPLICATION FOR
AUTHORISED AGENT
LICENCE

Programme FORM 1

Please read the following explanatory notes carefully. Please submit application in electronic
and printed form
1. In accordance with Section 31 of the Citizenship by 5. Applicants applying as a company:
Investment Act, No. 14 of 2015, the Citizenship by Investment a. Need not complete Section 3
Unit (“the Unit”) shall appoint authorised agents who will be b. Must provide:
licenced to submit applications for Citizenship by Investment • Certificate of Incorporation
on behalf of applicants to the Citizenship by Investment • Articles of Incorporation
Programme (“CIP”). • Notice of Directors (notice of a change of directors or
shareholders must be submitted to the Unit forthwith)
2. The Unit shall appoint authorised agents whose professional • Notice of Company’s Registered Office in Saint Lucia
qualifications, ability, resources, expertise, integrity and/or • Articles of Continuation or By Laws (if applicable)
conduct conform to the guidelines issued by the Unit. • Income Tax Clearance Certificate
• NIC Clearance Certificate
3. The guidelines for authorised agents are attached. Please • Audited financial statement for the period
review them carefully before submitting an application. immediately preceding the application

4. Applicants applying as individuals 6. Applicants applying as a partnership:

a. Need not complete Sections 2, 3 and 8 a. Need not complete Sections 2 and 8
b. Must provide certified copies of: b. Must provide:
• Two of the IDs detailed in Section 1 – number 1.4. • Certificate of Registration
• Academic and professional certificates • Income Tax Clearance Certificate
• Curriculum Vitae • NIC Clearance Certificate
• Income Tax Clearance Certificate • Audited financial statement for the period
• NIC Clearance Certificate immediately
• Statutory Declaration (See Attachment 1A)

1. APPLICANT INFORMATION

1.1 Full Name

Last Name First Name

Other Name(s)

1.2 Address

Permanent Address

City Country Zip Code

1.3 Contact Details

Home Telephone Number Mobile Telephone Number Work Telephone Number Facsimile Number

Email Address
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1.4. Identification (Please provide a copy of the ID for which you have provided the details )

Social Security Number (SSN)

National ID Card Number Exp. Date (DD/MM/YY)

Passport Number Exp. Date (DD/MM/YY)

Driver’s Licence Number Exp. Date (DD/MM/YY)

1.5 Are you a resident of Saint Lucia?

Yes No

If yes, how long have you been a resident? (YEARS, MONTHS) If no, which country or countries are you a resident of?

2. COMPANY INFORMATION

2.1 Name of Entity 2.2 Type of company (business activity or purpose)

2.3 Company Number 2.4 Incorporation Date 2.5 Country of Incorporation

(DD/MM/YY)

2.6 Registered Address

Address

City Country Zip Code

2.7 Business Address (if different from 2.6 above)

Address

City Country Zip Code

2.8 Business Address (if different from 2.7 above)

Address

City Country Zip Code

APPLICATION FOR AUTHORISED AGENT

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2.9 Business Contact Information

Telephone Number Facsimile Number

Email Address Website

3. PARTNERSHIP INFOMATION

3.1 Business Name 3.2 Type of Partnership (business activity or purpose)

3.3 Registration Number 3.4 Country of Registration

3.5 Business Address

Address

City Country Zip Code

3.6 Business Mailing Address (if different from 3.5 above)

Address

City Country Zip Code

3.7 Business Contact Information

Telephone Number Facsimile Number

Email Address Website

4. AUTHORISED REPRESENTATIVE

Please complete for the person who is authorised to accept service of process and any notices required to be served on it on behalf of
the applicant 4.1 Full Name

Last Name First Name

Other Name(s)

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4.2 Address

Permanent Address

City Country Zip Code

4.3 Contact Details

Telephone Number Facsimile Number

Email Address Website

5. AUTHORISED REPRESENTATIVE ALTERNATIVE

Please complete for the person who is authorised, in the absence of the person named in 4 above, to accept service of process and any
notices required to be served on it on behalf of the applicant.

5.1 Full Name

Last Name First Name

Other Name(s)

5.2 Address

Business Address

City Country Zip Code

5.3 Contact Details

Telephone Number Facsimile Number

Email Address Website

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6. ATTORNEY-AT-LAW ( If any )

6.1 Full Name

Last Name First Name

Other Name(s)

6.2 Address

Business Address

City Country Zip Code

6.3 Contact Details

Telephone Number Facsimile Number

Email Address Website

7. CHARTERED ACCOUNTANT

7.1 Full Name

Last Name First Name

Other Name(s)

7.2 Address

Business Address

City Country Zip Code

7.3 Contact Details

Telephone Number Facsimile Number

Email Address Website

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8. SUBSIDARY COMPANY INFORMATION ( If applicable )

Please provide details of the subsidiary companies of the Authorised Agent where the Authorised Agent is a company. Attach additional
sheets if required.

Company 1

Name Statement of Capital

Address

City Country Zip Code

Company 2

Name Statement of Capital

Address

City Country Zip Code

The undersigned hereby affirms that the information contained in this application is true and accurate as of the date shown below
and the undersigned is authorised to execute this application.

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APPLICANT

Name

Signature

APPLICATION FOR AUTHORISED AGENT