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Bail Registration Form (2014) - Delaware

Bail Registration Form (2014) Form. This is a Delaware form and can be used in Court Of Common Pleas Statewide .
 Fillable pdf Last Modified 7/21/2014
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Court of Common Pleas for the State of Delaware COUNTY: SECTION: 1 DESIGNATION (check one): TYPE OF BAIL (check one): Bail Agent Cash only Designated Bail Agent Surety Business Entity Cash & Surety Statewide New Castle Kent Sussex BAIL REGISTRATION FORM Individual Name: _________________________________________________________________________________ Legal Name of Firm: ______________________________________________________________________________ If business, full Legal Name of business on file with the Internal Revenue Service (IRS) Doing Business as/Trade Name(s) if applicable: _________________________________________________________ As registered in the respective county's Prothonotary's Office Office Address: ___________________________________________________________________________________ (NOTE: A Post Office Box is unacceptable.) Street Address Apt / Suite / Other City State ZIP CodeTM Telephone Number: (______)_________________ Area Code Number Employer Identification Number: ______________________ Driver Attach a photocopy State of E-Mail address: _____________________________________ License No.:___________________ Origin: __________ Name of the firm's Designated Bail Agent: _____________________________________________________________ ATTACH A COPY OF EACH APPLICABLE LICENSE Delaware Dept. of Insurance Provider License: Number Expiration Date Delaware Dept. of Insurance Business License: Delaware Division of Revenue Business License: City of Wilmington Business License: City of Dover Business License*: Town of Georgetown Business License: Municipality Business License: *Denotes license expires on June 30th. Have you ever been convicted of a felony? YES NO If yes, when and where ______________________________ _______________________________________________________________________________________________. Has an Insurance or Business License ever been revoked, suspended or denied? YES NO If yes, state the license type, reason where and where. ______________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________. Attach additional sheets of paper as necessary. INSURANCE/ SURETY COMPANY: Name: ___________________________________________ Street Address Apt / Suite / Other National Association of Insurance Commissioners Number: _______________ City State ZIP CodeTM Address: ________________________________________________________________________________________ Telephone Number: (______)__________ Area Code Number E-Mail address: ______________________________________________ I hereby acknowledge that I have been provided and read a copy of the Court of Common Pleas Rules of Conduct for Bail Agents and Property Bail Agents (Rules of Conduct). Furthermore, I understand that the provisions set forth in the Rules of Conduct govern my conduct as a bail bond agent before this Court, and I agree to abide by all such provisions. I further agree to notify the Court, in writing, as soon as practicable, but in no event later than ten (10) American LegalNet, Inc. www.FormsWorkFlow.com calendar days of any changes to the information as set forth on this Bail Registration Form. Under penalty of law, I do hereby attest that all statements in the foregoing Bail Registration Form are true and correct. I am aware that if any of the foregoing statements are knowingly and willfully false, fictitious or fraudulent, I am subject to prosecution pursuant to 11 Del. C. § 877. ________________________________________________________ Notarized Signature ________________________________________________________ Print Name of Applicant and Title SWORN to and subscribed before me on this _______________ day of __________________________ 20_________ Notary Public (Seal) Signature: _______________________________________________ My Commission Expires: ____________________________________ SECTION: II ­ COMPLETE AS APPLICABLE GUARANTOR TO SATISFY BAIL FORFEITURE JUDGMENTS FOR ABOVE LISTED BAIL AGENT/BUSINESS ENTITY/DESIGNATED BAIL AGENT: The person or entity listed below has provided the bail agent / business entity and /or insurance / surety company with a guarantee to pay bail forfeiture judgments associated with said bail written by the bail agent / business entity / designated bail agent listed in SECTION I: Name: __________________________________________________________________________________________ Delaware Department of Insurance License #: _________________________________ Exp. Date: ________________ Address: ________________________________________________________________________________________ Street Address Apt / Suite / Other City State ZIP CodeTM Telephone Number: (______)_________________ Area Code Number E-Mail address: _______________________________________ CERTIFICATION BY INSURANCE/SURETY COMPANY: I certify that the insurance / surety company listed in SECTION I is authorized and admitted to transact surety business by the Delaware Department of Insurance. The above named bail agent / business entity / designated bail agent is authorized to write bail bonds on behalf of that insurance company in Delaware and is licensed as an insurance producer by the Delaware Department of Insurance. I certify that the foregoing statements made on this Bail Registration Form are true and correct. I am aware that if any of the foregoing statements in SECTION II of the Bail Registration Form are knowingly and willfully false, fictitious or fraudulent, I am subject to prosecution pursuant to 11 Del. C. § 877. _________________________________________________ Notarized Signature of Corporate Officer _________________________________________________ Print Title ____________________________________________________________________ Print Name SWORN to and subscribed before me on this _______________ day of __________________________ 20_________ Notary Public (Seal) Signature: _______________________________________________ My Commission Expires: ____________________________________ Submit original registration form along with a duly authenticated original power of attorney along with all other required attachments to: Bail Bond Registration, Court of Common Pleas, 500 N. King St., Ste. 2800, Wilmington, DE 19801-3754 American LegalNet, Inc. www.FormsWorkFlow.com
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