Superior Court of the State of Delaware  New Castle COUNTY:  Kent  Sussex BAIL REGISTRATION FORM SECTION I DESIGNATION (check one)  Bail Agent  Designate Bail Agent  Business Entity TYPE OF BAIL (check one)  Cash Only  Surety Only  Cash & Surety AUTHORIZED TO PICK UP CASH:  YES  NO Name: ______________________________________________________________________________________ Office Address: _______________________________________________________________________________ Street City State Zip Code List the Days of the Week and the Hours the Office is Open: ___________________________________________ Telephone: _______ __________________ Area Code Employer Identification No.:__________________________ Number Email: _____________________________ ATTACH A COPY EACH APPLICABLE LICENSE Number Expiration Date Delaware Dept. of Insurance Provider License: Delaware Dept. of Insurance Business License: Delaware Div. of Revenue Business License: Local/Municipality Business License: Have you ever been convicted of a felony? __ Yes __ No. If Yes, where and when ____________________________. Has any Insurance or Business License been revoked, suspended or denied. __Yes __ No. If Yes, state the license type, reason, where and when. ___________________________________________________________________________. INSURANCE/SURETY COMPANY: Name: _____________________________________ N.A.I.C.#__________________________________ Address: _____________________________________________________________________________________ Street Telephone: ___________________ City State Zip Code Email: ____________________________________ Area Code Number I hereby acknowledge that I have been provided and read a copy of Superior Court’s Administrative Directive 2012-4. I further understand that the provisions set forth in this Administrative Directive govern my conduct as a bail bond agent before this Court. I agree to abide by all the provisions of this Administrative Directive and further agree to notify the Prothonotary, in writing, as soon as practicable but in no event later than 10 business days of any changes to the information as set forth on this Bail Registration Form. Date: _________________________ ________________________________________________ Notarized Signature and Title ________________________________________________ Notary Signature For Business Entity Registration Only: Name of Designated Bail Agent: ________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com SECTION II - COMPLETE IF APPLICABLE GUARANTOR TO SATISFY BAIL FORFEITURE JUDGMENTS FOR ABOVE LISTED BAIL AGENT/BUSINESS ENTITY/DESIGNATED BAIL AGENT: The person or entity listed below has provided the bail agent/business entity and/or insurance/surety company with a guarantee to pay bail forfeiture judgments associated with bail recognizance written by the bail agent/business entity/designated bail agent listed in SECTION I: Name: ______________________________________________________________________________________ Delaware Department of Insurance License #: _______________________________________________________ Exp. Date: __________________ Address: ____________________________________________________________________________________ Street City State Zip Code Telephone: ____________ _________________________ Area Code Number (ATTACH A COPY OF THE GUARANTOR’S LICENSE) CERTIFICATION BY INSURANCE/SURETY COMPANY: I certify that the insurance/surety company listed in SECTION I is authorized and admitted to transact surety business by the Delaware Department of Insurance. The above named bail agent/business entity/ designated bail agent is authorized to write bail bonds on behalf of that insurance company in Delaware and is licensed as an insurance producer by the Delaware Department of Insurance. I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. I understand it is my obligation to update the information contained herein as changes occur in order to assure that the information remains complete and accurate. Dated: ____________________ ______________________________________________ Signature of Corporate Officer __________________________________________ Title __________________________________________ Print Name Mail or hand deliver the original registration form along with the original power of attorney and other required attachments to each Prothonotary’s Office in each county in which you intend to conduct business:  New Castle County Courthouse, 500 N. King Street, Suite 500, Wilmington, DE 19801  Kent County Courthouse, 38 The Green, Dover, DE 19901  Sussex County Courthouse, 1 The Circle, Suite 2, Georgetown, DE 19947 American LegalNet, Inc. www.FormsWorkFlow.com