APPLICATION AND AFFIDAVIT FOR PLACEMENT ON LIST OF APPROVED PRIVATE PROCESS SERVERS This form must be completed in its entirety in order to be considered for approval. Incomplete forms will be returned without explanation. Process Server’s Information: Legal Name: ____________________________________________________________________ Current Address: ________________________________________________________________ City/State/Zip _____________________________Telephone Number: _____________________ Primary occupation: ______________________________________________________________ Name of employer: _______________________________________________________________ Percentage of work allocated to service of process: ______________________________________ Please describe your experience and background in performing service of process: ___________________ ______________________________________________________________________________________ I, _____________________________________, being duly sworn under oath and penalty of perjury (Name of Process Server) do hereby state that I meet the following qualifications: ____ (Indicate with your hand-written initials each qualification that applies.) I am at least eighteen (18) years of age; ____ I am a citizen of the United States; ____ I have a high school diploma or equivalent; ____ I have not plead guilty or been convicted of a felony or a misdemeanor involving moral turpitude; ____ I am not a fugitive from justice or charged with a felony or a misdemeanor involving moral turpitude; ____ I am not related to or employed (except as a private process server) by a party in the action; ____ I am of good moral character; ____ I will not serve process in any jurisdiction unless I am authorized by law to serve process within the jurisdiction where such service is made; and ____ I have not been disqualified by any court to act as a process server within the preceding twelve (12) months. ___________________________________________ Process Server’s Signature STATE OF MISSOURI COUNTY OF JACKSON ) ) SS. Subscribed and sworn to before me on _____________________________________________________ (Seal) ____________________________________________ Notary Public My Commission Expires:_________________________________________________ Note: It is a Class A Misdemeanor to make a false affidavit for the purpose of misleading a public servant. Section 575.050 RSMo 01-28-2010 This form is continually reviewed for needed revisions. Please bookmark the appropriate court webpage and download this form each year to ensure that you have the most current form. American LegalNet, Inc. www.FormsWorkFlow.com