Free Professional Bondsman/Agent Information - Maryland

DISTRICT COURT OF MARYLAND
580 Taylor Avenue, A-3 Annapolis, MD 21401

PROFESSIONAL BONDSMAN/AGENT INFORMATION SHEET Bail Bondsman Category
Property Bail Bondsman Agent Bail Bondsman (Property) Surety Bail Bondsman

General Information
Name
(First) (Street) (Middle) (City) (Last) (State) (Suffix) (Zip Code)

Residence Address Business Name Business Address Home Phone

(Street)

(City)

(State) (Area Code)

(Zip Code) (Area Code)

(Area Code)

Business Phone Date of Birth:

Fax

Social Security Number Driver's License Number

Email Address: State Expiration Date

Convictions: The questions below do not apply to traffic violations involving a fine of $100.00 or less and/or convictions that occurred before your 16th birthday. Yes No Have you ever been convicted of anything other than a minor traffic violation in Maryland? If yes, provide details. If convicted on more than one occasion, explain each case.

Property Bail Bondsman
Inventory of real estate of which you are the sole owner in fee simple absolute or as chattel real estate subject to ground rent (attach additional sheets if more space is needed). While the bond is in effect, the land or premises or any interest therein may not be sold, transferred, conveyed, assigned, or encumbered. Any intended change must be reported to District Court Headquarters within 30 days of the change. Any change in title without the consent of the court will invalidate the bond. Bond shall not exceed available net equity on posted property. A copy of the most recent tax bill for each property listed is required (please attach). Legal Description City Zone Street Number Street

Note: 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.) Last Name First Name Middle Name Suffix

Agent Bail Bondsman (Property)
Full Legal Name of Employing Property Bail Bondsman:
(First) (Middle) (Last) (Suffix)

Is a Power of Attorney on file with District Court Headquarters and Circuit Court RP 4-107?
JPR03 (3/24/2008)

Yes

No*

(*If No, please attach.)
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Surety Bail Bondsman
Power of Attorney: List all insurance companies. Please attach an original signed qualifying power of attorney for each company. Insurance Company Name Registered Agent

Maryland Insurance Property and Casualty License Number Expiration Date

Affirmation
I hereby affirm that this form contains no willful misrepresentations or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any misrepresentation or falsification, my name will be removed from the active property bondsman listing. I am aware that a false statement is punishable under law by fine or imprisonment or both. By signing this document, I authorize the performance of a criminal record check.

Print Name: Signature

Date Signed:

Please ensure you have enclosed all necessary documentation. # Attachments

JPR03 (3/24/2008)

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AUTHORIZATION FOR RELEASE OF INFORMATION

I, , do hereby authorize the release, review and full disclosure of all records, or any part thereof, concerning myself, to any duly authorized agent of District Court of Maryland whether the said records are of a public, private or confidential nature. The purpose of this authorization is to give my consent for full and complete disclosure of the records of any: · Records of complaint, arrest, trial and/or convictions for alleged or actual violations of law, including criminal and/or traffic records; and, · Records of complaints of a civil nature made by or against me, wherever located, including the records and recollections of attorneys at law or other counsel, whether representing me or another person in any case which I have ever been a party or had an interest. I understand that the District Court of Maryland conducts routine background checks on prospective agents. It is my intention that the District Court of Maryland has access to all data and records of the type listed above which may deem appropriate; and, whether or not documents are specifically named herein, I freely grant such access. I understand that having the ability to write bonds in the District Court of Maryland is contingent upon the satisfactory results of this background check. In the event that I am denied the right to post bonds in District Court of Maryland, the source of any confidential information will not be revealed to me. I agree to indemnify and hold harmless the person to whom this request is presented, as well as his agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of or by reason of complying with this request. This release form and any photocopy of this release form, even though the said photocopy does not contain an original writing of my signature, will be valid and should be honored for a period of one (1) year from the date of my signature. Printed Name Signature Address Date of Birth Date of Signature Social Security #

JPR03 (3/24/2008)

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