ABC Bail Bonds is AMERICA'S BAIL COMPANY. CALL 877-FAST-BAIL. Over 40 ABC Agents in NJ and PA to serve you 24 hours a day and 7 days a week.

PRINTABLE BAIL AGENT QUESTIONNAIRE & APPLICATION

A. General Information:
Name
Home Address
City
State	Zip
Length of Time at that Address
Home Phone
Pager No.
Cellular No.
Previous Address(es) for Past 5 years



Social Security#
Driver's License#
Are you presently in the bail bond business?	YES NO
If so, how long?
License #
Current Surety Company
What volume of business are you now writing:
Agency Name or Affiliation
Business Address
City
State	Zip
Business Phone Number

List below any Companies or General Agents with whom you have ever done Bail Bond Business and/or been appointed with: Dates:Company or General Agent:

(if applicable, indicate Professional Bondsman)

If not currently a bail agent, provide your current occupation, employer's name, business address and phone number, and name of supervisor:

Can your present employer be contacted?

YES

NO
How did you hear about our Company?

B. General Questions:

Do you currently have a Build-up Fund with another Company or General Agent?

YES

Has any Insurance Company or General Agent of County/Parish/Jurisdiction terminated business with you in the past?

YES

NO
If YES, When:

By Whom:

Reason:

Has it ever been necessary for payment of Forfeitures, Estreatures or Judgements to be paid out of your BUF or by the Company?

YES

NO
If YES, please explain:

Are you indebted (other than accounts current) to any insurance company, producer or insured or has any judgment ever been rendered against you for money received from or owed to any insurance company, producer or insured?

YES

Have you had any business or professional license suspended or revoked or are such proceedings pending against you?

YES

Has any disciplinary action ever been taken against you by any public authority (including a law enforcement agency or the Department of Insurance)?

YES

Have you ever previously held an insurance or bail agent's license in any state?
YES NO

Have any Judgements, Suits, Tax Liens, or Bankruptcies, been filed against you?
YES NO

Have you ever been arrested or charged with a crime?
YES NO
If YES, Where
When
Charge Disposition:

Are you a jailer, law enforcement officer, or do you have any custody or control over prisoners?

YES NO

NOTE: If you answered YES to any of the above questions, give further details on an attached sheet, and provided documentation.

C. Additional Information:
Please submit name, address and phone number of three personal references:

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Please submit the name, address, telephone number and contact person at Banks or other Financial Institutions that can serve as a reference on your behalf:

Bank Name
Location
Contact Person
Phone

Please provide detailed business and personal Financial Statements.

D. Certifications and Authorizations:

1.I hereby certify that all of the information submitted in this Questionnaire & Application and all attachments is true and complete; and

2.I hereby authorize ABC Bail Bonds (including any of its representatives, affiliates, agents or designees [collectively "you"]) to conduct any and all investigative inquiries pertaining to me including obtaining consumer reports, investigative consumer 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 request 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 source deemed necessary. I hereby agree to execute such other and further documents as may be requested in order to confirm the authorizations herein contained. This signed Questionnaire & Application (including any copy of same) shall serve as written instruction on my behalf to any company to provide the requested information.

In Witness Whereof, I have signed this Bail Agent Questionnaire & Application,
this

day of

, 20

Witness:

(Seal)

Please make certain to include your personal financial statement when submitting the questionnaire and application.

You may use the following personal financial statement form or any other personal financial statement form of your choice.

PERSONAL FINANCIAL STATEMENT

NOTE: This form to be used for Personal Financial Statements only.

Personal financial statement of ,
this day of , 19 .

Address
Home Phone
Business Phone
S.S. No.

	CURRENT ASSETS
Cash on hand (not in bank) $
Cash in banks (Itemize on schedule 1) $
Marketable Stocks and bonds (Itemize on schedule 2) $
Notes & Accounts receivable (Itemize on schedule 3) $
Other current assets (itemize) $
$
$
$
$
TOTAL CURRENT ASSETS $

	FIXED ASSETS
Real estate (Itemize on schedule 4) $
Residence $
Other $
Cash value of life insurance (Itemize on schedule 5) $
Other assets and investments (including non-marketable securities) $
$
$
TOTAL FIXED ASSETS $
TOTAL ASSETS $

	CURRENT LIABILITIES
Notes payable to (names and addresses)
Amount $
Notes payable to (names and addresses)
Amount $
Notes payable to (names and addresses)
Amount $
Sales Contracts & Chattel Mtgs. $
Accounts Payable $
Current portion of long term debt $
Other current liabilities $
$
$
Current Years Income Taxes Unpaid $
Prior Years Income Taxes Unpaid $
Real Estate Taxes Unpaid $
TOTAL CURRENT LIABILITIES $

	LONG TERM LIABILITIES
Real estate debt (Itemize on schedule 4) $
Residence $
Other $
Borrowed on life insurance (Itemize on schedule 5) $
Other long term debt (Itemize on schedule 6) $
$
$
$
TOTAL LONG TERM LIABILITIES $
NET WORTH $
TOTAL LIABILITIES AND NET WORTH $

	CONTINGENT LIABILITIES
FOR ENDORSEMENT OR GUARANTEES $
FOR OTHER PURPOSES $
GIVE DETAILS




	SCHEDULE 1. CASH IN BANKS
Name of Bank:
Address:
Account No.:
Amount:
Name of Bank:
Address:
Account No.:
Amount:
Name of Bank:
Address:
Account No.:
Amount:
TOTAL

	SCHEDULE 2. MARKETABLE STOCKS AND BONDS If any pledged,
Name of Security:
No. Shares and for what purpose
Market Value
Broker
Name of Security:
No. Shares and for what purpose
Market Value
Broker
Name of Security:
No. Shares and for what purpose
Market Value
Broker
TOTAL $

	SCHEDULE 3. NOTES & ACCOUNTS RECEIVABLE
Name
Address(street and city)
From Whom
Due
How Secured
Date
Maturity
Amount
Name
Address(street and city)
From Whom
Due
How Secured
Date
Maturity
Amount
Name
Address(street and city)
From Whom
Due
How Secured
Date
Maturity
Amount
TOTAL $

	SCHEDULE 4. REAL ESTATE
Description of Property
Title in Name Of
Market Value
Cost
Date Acquired
Amount of Encumbrance
Monthly Payments
Monthly Income
Description of Property
Title in Name Of
Market Value
Cost
Date Acquired
Amount of Encumbrance
Monthly Payments
Monthly Income
Description of Property
Title in Name Of
Market Value
Cost
Date Acquired
Amount of Encumbrance
Monthly Payments
Monthly Income
TOTAL Market Value $
TOTAL Cost $
TOTAL Amount of Encumbrance $
TOTAL Monthly Payments $
TOTAL Monthly Income $
TOTAL Market Value $
TOTAL $

	SCHEDULE 5. LIFE INSURANCE - CASH VALUE
Name of Company
Policy Number
Name of Insured
Beneficiary
FaceValue
Amount Borrowed
Name of Company
Policy Number
Name of Insured
Beneficiary
FaceValue
Amount Borrowed
Name of Company
Policy Number
Name of Insured
Beneficiary
FaceValue
Amount Borrowed

	SCHEDULE 6. OTHER ASSETS AND LIABILITIES*





	ANY OTHER PERTINENT INFORMATION*

I hereby certify and declare that the above statement presents accurately my financial condition to the best of my knowledge and belief and I hereby authorize and request any person, firm or corporation to furnish all information requested by ABC Bail Bonds, or any of its sureties or reinsurers (hereinafter collectively called the "Surety") concerning any transaction with the undersigned; and the said Surety is authorized to obtain information to confirm this financial statement and may furnish copies of the foregoing statement and any information which it now has or may hereafter obtain to other companies for the purpose of securing reinsurance of co-suretyship.

WITNESS
SIGNATURE

* Attach additional sheets if necessary f:.stm

Please print out and fax to 215-295-9237

215 West Bridge Street, Morrisville, PA 19067
Phone: 215-295-3100 • Toll Free: 877-797-2245