Professional Bondsman Agent Information Sheet {JPR 3}

General Information Name(First)(Middle)(Last)Business Address(Street)(City)(State)(Zip Code)Home Phone(Area Code)Inventory of real estate of which you are the sole owner in fee simple absolute or as chattel real estate subject toground rent (attach additional sheets if more space is needed). While the bond is in effect, the land or premises or anyinterest therein may not be sold, transferred, conveyed, assigned, or encumbered. Any intended change must bereported to District Court Headquarters within 30 days of the change. Any change in title without the consent of the courtwill invalidate the bond. Bond shall not exceed available net equity on posted property.PROFESSIONAL BONDSMAN/AGENT INFORMATION SHEETDISTRICT COURT OF MARYLANDDriver's License NumberStateExpiration DateResidence Address(Street)(City)(State)(Zip Code)Business Phone(Area Code)Business Name Property Bail BondsmanEmail Address:Fax(Area Code)(Suffix)JPR-003 (Rev. 04/2018)A copy of the most recent tax bill for each property listed is required (please attach). Bail Bondsman Category580 Taylor Avenue, A-3Annapolis, MD 21401Page 1 of 2 Agent Bail Bondsman (Property)Full Legal Name of Employing Property Bail Bondsman:(First)(Middle)(Last)Is a Power of Attorney on file with District Court Headquarters and Circuit Court RP 247 4-107?YesNo*(*If No, please attach.)(Suffix)Agent Bail Bondsman (Property)Surety Bail BondsmanProperty Bail BondsmanNote: You will not be authorized to secure real estate that has not been identified and filed with the court. List all agent property bail bondsmen in your employment: (attach additional sheets if more space is needed.) Legal Description City Zone Street Number Street Last Name First Name Middle Name Suffix American LegalNet, Inc. www.FormsWorkFlow.com Power of Attorney: List all insurance companies. Please attach an original signed qualifying power of attorney for eachcompany.I hereby affirm that this form contains no willful misrepresentations or falsifications and that this information given by meis true and complete to the best of my knowledge and belief. I am aware that should investigation at any time discloseany misrepresentation or falsification, my name will be removed from the active property bondsman listing. I am awarethat a false statement is punishable under law by fine or imprisonment or both. Surety Bail BondsmanDate Signed:Signature Maryland Insurance Property and Casualty License Number AffirmationPrint Name:Please ensure you have enclosed all necessary documentation.# AttachmentsPage 2 of 2JPR-003 (Rev - 04/2018)Expiration Date Insurance Company Name Registered Agent American LegalNet, Inc. www.FormsWorkFlow.com