APPLICATION FOR BAIL BOND APPOINTMENT

(Please print or type -Do Not Abbreviate)

First Name *

Last Name *

Male or Female?

SS# *

Date of Birth *

Agent Status requested *

How did you hear about us. *

Home Address *

Apt. or Suite

City *

State *

Zip Code *

Home Phone Number *

County *

Email Address *

License# *

Mobile Phone Number *

Bus. Phone Number *

Fax

Married? *

Name of Spouse

Are you currently an MGA? *

If so, for how long?

Number of Agents? *

List all insurance companies you currently write for: *

Do you currently owe an MGA or Insurance company premium money? *

Do you currently owe an MGA or Insurance company Forfeiture money? *

Do you currently have any outstanding skips or Forfeitures? *

How many? *

Why do you want to join Surety 3 ? *

Volume of Business You're Writing? *

Have you ever plead guilty (or) nolo contendre to (or) been guilt of a felony (or) crime involving moral turpitude? *

Total Number of Estreatments *

Total Number of Estreatments last year? *

Has any disciplinary action, including but not limited to, refusal, suspension, revocation, ever been taken by any regulatory agency in any state against you or any business with which you have been directly connected? *

Do you currently have a Build Up Fund with another Surety, Company or General Agency? *

Are you transferring your Build Up Fund to us or starting a new buf? *

If yes, how much is in the account? *

Current Employer Name (Company) *

Owner Name *

Bus. Street Address, State, Zip Code *

Total Assets *

IRA *

Home Mortgage *

Contingent Guaranty

Other Real Estate *

Stocks/Bonds *

Other Assets *

Cash *

Please submit the name, address and phone number of three references:

1) Name *

Address *

Phone Number *

2) Name *

Address *

Phone Number *

3) Name *

3) Address *

3) Phone Number *

APPOINTMENT COUNTIES (LICENSE AGENT ONLY)

COUNTIES *

Please, Upload - (scan or clear photo of your bonding license and ID, drivers license or passport) *

CONSENT AND WAVIER

RE TITLE 28 PRIVACY ACT FREEDOM OF INFORMATION ACT,TITLE 6 FAIR CREDIT REPORTING ACT,PUBLIC LAW91-508

In connection with my application for bail bond agency Ibail bond agent with SURETY 3 GENERAL AGENCY, INC., I understand that investigative inquiries are to be made on myself including consumer. criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further. I understand that you will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my credit, criminal, civil and other experiences as well as claims involving me or the files of insurance companies.

I authorize, without reservation, any party or agency contacted by SURETY 3 GENERAL AGENCY, LLC ./ PALMETTO SURETY CORPORATION to furnish the above mentioned information.

I have a right to make a written reauest. within a reasonable period of time, to receive additional detailed information about the natureand scope of this investigation.

I hereby consent to your obtaining the above information from National Credit information Network and / or other source deemed necessary, and agree that such information you obtain, and my experience with you, if I am contracted and appointed, wiII be accessible through you by future companies to which I might apply.

Date *

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