Professional Bondsmen Application

State of New Hampshire Bureau of Securities Regulation PROFESSIONAL BONDSMEN APPLICATION 1. FULL NAME, HOME ADDRESS AND BUSINESS OF THE APPLICANT: D/O/B ___/___/___ SOCIAL SECURITY # ___________ DRIVERS LICENSE # __________ 2. NAME OF EMPLOYERS AND ADDRESS: 3. PERSONAL FINANCIAL STATEMENT OF THE APPLICANT: ANNUAL AND MONTHLY INCOME: $_________ / $_________ PER YEAR APPLICANT $_________/ $_________ PER YEAR APPLICANTS SPOUSE OTHER ASSETS: MONTHLY EXPENDITURES: 4. PASSPORT PHOTO _________ ATTACHED. 5. APPLICANTS THUMBPRINTS _________ ATTACHED. 6. DESCRIPTION OF ALL ARRESTS AND CONVICTIONS OF THE APPLICANT WHICH HAVE NOT BEEN ANNULLED BY A COURT OF LAW: <<<<<<<<<********>>>>>>>>>>>>> 2Bureau of Securities Regulation Professional Bondsmen Application Page 2 7. DESCRIPTION OF ANY LICENSE ISSUED OR DENIED TO THE APPLICANT BY THE NEW HAMPSHIRE INSURANCE DEPARTMENT: 8. DESCRIPTION OF ANY LICENSES ISSUED OR DENIED TO THE APPLICANT RELATIVE TO THE BAILBOND BUSINESS BY ANY GOVERNMENT AGENCY: 9. DESCRIPTION OF APPLICANTS EXPERIENCE IN LAW ENFORCEMENT OR LAW ENFORCEMENT RELATED OCCUPATION: 10. A GENERAL POWER OF ATTORNEY FROM A SURETY COMPANY WILL BE PROVIDED BY: 11. A FIDELITY BOND WILL BE PROVIDED BY: 12. IF THE APPLICANT IS NOT A RESIDENT OF NEW HAMPSHIRE, THE SECRETARY OF STATE HAS BEEN APPOINTED AS "AGENT" FOR SERVICE OF PROCESS. THE APPLICANT SHALL BE SUBSCRIBED WITH THE SWORN STATEMENT THAT THE INFORMATION CONTAINED HEREIN IS TRUE. ______________________ APPLICANT ______________________ DATE SIGNED AND SWORN BEFORE ME TO BE TRUE ______________________ MY COMMISSION EXPIRES ______________________