Name__________________________________________________________________________________________________________
Name of Agency_________________________________________________________________________________________________
Home Address__________________________________________________________________________________________________
City _________________________________________________ State ____________________ Zip ____________________________
Length at this address ________________________________ Home Phone________________________________________________
Pager # ___________________________________ Cell # ______________________________ Office# __________________________
Social Security Number ___________________________________________________ DOB __________________________________
Driver Lic. # ______________________________________________ Insurance Lic. # ________________________________________
Spouse Name____________________________________________ DOB: _________________ Social Security # _________________
Business Address __________________________________________________________City ___________ State Zip _____________
Are you presently in the Bail Bond Business? _____________ Annual Gross Liability_________________________________________
How long? _____________ Forfeiture ratio ______________________________ BUF balance __________________________________
Current Surety __________________________________________________________________________________________________
List all Sureties or GA’s with whom you have done business: ____________________________________________________________
If not currently in the bail business provide your current occupation, employer’s name, address, phone number.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
I hereby authorize AA Dependable Bail Bonds (including any of its representatives, affiliates, agents or designees [collectively “you”]) to conduct any investigative inquiries pertaining to me including obtaining consumer reports, investigative consumer reports, audit reports, criminal records, driving records, and such other reports that it deems necessary. These inquiries and / or reports, may include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I authorize you to request and obtain information from any federal, state and other agencies which may maintain records concerning my past activities relating to my credit, criminal, civil and other experiences, as well as claims involving me in the files of insurance companies. I authorize, without reservation, any party or agency contacted by you to furnish the above mentioned information. I acknowledge the right to make a written to request AA Dependable Bail Bonds within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I specifically consent to you obtaining the above information from U.S. Datalink, National Credit Information Network (W.D.I.A.), or other sources deemed necessary. I hereby agree to execute any additional documentation necessary to confirm this instruction and authorization. This signed Questionnaire & Application (including any copy of the same) shall serve as written instruction and authorization on my behalf to any company to provide the requested information.
In Witness Whereof, I have signed this Bail Agents questionnaire & Application,
This ____________ Day of _______________________, 20____.
Sign-__________________________________________ Witness _______________________________________________
PERSONAL FINANCIAL STATEMENT
Personal financial Statement as of _____________________________
Assets:
Cash on hand $ ______________________
Cash in Bank $_______________________
Stocks and Bonds $ ___________________
Other Assets List :
________________$__________________
________________$__________________
________________$__________________
Real estate (home)$__________________
Investments list:
________________$_________________
________________$_________________
________________$_________________
Total Assets: $______________________
Total Net Worth $ _________________________________
Liabilities:
Mortgage $ ___________________________
Auto Loans $__________________________
Credit cards $ _________________________
Notes Payable $ _______________________
IRS $ ________________________________
Other Loans List:
__________________ $ _________________
__________________ $_________________
Total liabilities: $ ______________________
APPLICATION FOR BAIL BOND AGENCY
(Please type or print)
Toll Free: 800-597-6708 Office: 301-475-9565 or 301-862-9853 Cell: 240-538-5421 Direct: 301-904-5706
AA Dependable Bail Bonds: 40900 Merchants Lane, Suite #203, Leonardtown, MD 20650.
Privacy Statement:
The information which you give in completing this form will be used in processing your application for agency with us, and will not be used for any other purpose or provided by us to any other parties.
