Bail Agent Registration Form (2016)

The Administrativ Offic of the Cou A ve ce urts For the Sta of D r ate Delaware e BAIL AGENT REGISTRA A ATION FO ORM SE ECTION 1: Ge eneral DESIGNATION: TYP OF BAIL: PE Bail Age ent Cash Designated Bail Agent A Surety Only Yes Y Cash & Surety No AUTHORIZED TO PICK UP CASH: T C CO OURTS to which you are ap pplying: (SE ELECT ALL THA APPLY) HAT CO OUNTIES to which you are applying: w (SE ELECT ALL THA APPLY) HAT Family Court Court of Com mmon Pleas Justice of the Peace Co ourt County New Castle County Kent County y Sussex C Nam of Agent me Leg name of business: gal b Tra Name/Doing Business As (If Applica ade able): As registered in the respective count n ty's Prothonotary's Off fice, see 18 Del C. § 4 4350 (e) Tra Name/Doing Business As (If Applica ade able): As registered in the respective count n ty's Prothonotary's Off fice, see 18 Del C. § 4 4350 (e) Office Address: Street Apt / Suite / Other S City State Zip Telephone Number: Em address: mail Em mployer Identif fication Numb ber: (If sole proprietorship, use your Soc Security Number) cial Lic censing AT TTACH A COPY OF EACH APPL Y LICABLE DOCU UMENT Number Delaware Dept. of Insurance Producer Lic cense: Delaware Dept. of Insurance Business Lic cense: Delaware Div. of Revenue Bu usiness Licen nse: Loc cal/Municipali Business License(s): ity L Hav you ever been convict ve ted of a felon ny? Yes including when and where the offense was committed: a e s No If yes, state all pertinent facts and cir rcumstances Has the Department of Insurance ever re evoked, susp pended or de enied your bu usiness licens or has a Surety ever se, voked and/or suspended your insuran nce coverage e? Yes No If yes, state all pertinen facts and e nt rev circ cumstances. Ins surance/Sur rety Compa any Atta Power of Attorneys for Ea Court and County ach ach C Justice of the Peac Court Court of Common Pleas ce Family Co ourt Sur rety Power of Attorney ­ New Castle f N Sur rety Power of Attorney ­ Kent f K Sur rety Power of Attorney ­ Sussex f NOT Attach an orig TE: ginal Power of Atto orney, bearing the insurance compa e any's corporate sea for each county wherein you plan to conduct business. al, y n Nam me: Office Address: Street Apt / Suite / Other S N.A.I.C #: C. City State Zip Telephone Number: Em Address: mail Bail Agent Regist tration Form 20 016 P Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 2: To be completed by a designated bail agent only I Name of Designated Bail Agent having read this form in its entirety do certify that is affiliated with the bail bond entity named in SECTION 1. Name of Bail Agent Applicant Additionally, I have provided the Bail Agent with physical copies of the respective courts Policy Memorandum / Policy Directive which govern the conduct of a bail agent before each of the respective courts selected in SECTION 1. I certify that these statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. Notarized Signature and Title of the Designated Bail Agent Printed Name of Designated Bail Agent Sworn to and subscribed before me this day of , Notary Public My Commission Expires: Date GUARANTOR TO SATISFY BAIL FORFEITURE JUDGMENTS FOR ABOVE LISTED BAIL BUSINESS ENTITY The Guarantor listed below has provided the bail business entity with a guarantee to pay the bail forfeiture associated with bail recognizance written by the bail business entity listed in SECTION I: Name of Guarantor: DELAWARE DEPARTMENT OF INSURANCE INFORMATION License #: Address: Street Apt / Suite / Other City State Zip Telephone Number: Email Address: SECTION 3: To be completed by bail agent applicant only I hereby acknowledge that I have been provided and read a copy of ALL APPLICABLE COURTS' Policy Memorandum / Policy Directives Regarding Bail Bonds. I further understand that the provisions set forth in said Policy Memorandum / Policy Directives govern my conduct as a bail bond agent before the respective court. I agree to abide by all the provisions of said Policy Memorandum / Policy Directives and further agree to notify the Administrative Office of the Courts, in writing, as soon as practicable but in no event later than 10 business days of any changes to the information as set forth on this Bail Registration Form. Notarized Signature and Title of the Bail Agent Printed Name of Applicant and Title Sworn to and subscribed before me this day of , Notary Public Date Bail Agent Registration Form 2016 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4: To be completed by surety entity only 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 / 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 by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. I understand it is my obligation to update the information contained herein as changes occur in order to assure that the information remains complete and accurate. Notarized Signature and Title of the Corporate Officer Printed Name of Corporate Officer and Title Sworn to and subscribed before me this day of , Notary Public My Commission Expires: Date Mail or hand-deliver the original registration form along with the original power of attorney and other required attachments to the Administrative Office of the Courts, 405 N King Street, Suite 507, Wilmington, DE 19801-3700 Bail Agent Registration Form 2016 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com