Bail Entity Registration Form (2016)

The Administrativ Offic of the Cou A ve ce urts For the Sta of D r ate Delaware e BAIL ENTITY REGISTRA E ATION FO ORM SE ECTION 1: Ge eneral TYP OF BAIL: PE Cash Surety Only Cash & Surety Family Court Court of Common Ple f eas Justice of the Peace Co ourt County New Castle County Kent County y Sussex 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 Leg name of business: gal b Tra Name/Doing Business As (If Applica ade able): As registered in the respective county Prothonotary's Off n y's fice, see 18 Del C. § 4350 (e) Tra Name/Doing Business As (If Applica ade able): As registered in the respective county Prothonotary's Off n y's fice, see 18 Del C. § 4350 (e) Office Address: Street Apt / Su / Other uite City State Zip Telephone Number: Em address: mail Emp ployer Identifi fication Numb ber: (If sole propriet torship, use your Social Security Number) Lic censing AT TTACH A COPY OF EACH APPL Y LICABLE DOCU UMENT Number Exp piration Date 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 Delaware Dept. of Insurance Cert. of Auth hority: Has the Department of Insurance ever revoked, 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 ce Justice of the Peac Court Court of Common Pleas 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 Entity Registr ration Form 2016 6 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 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 Designated Bail Agent Printed Name of Applicant and Title Sworn to and subscribed before me this day of , Notary Public Date SECTION 2: COMPLETE AS APPLICABLE 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: 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 entity 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 Entity Registration Form 2016 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2