APPENDIX XXI [See Rule 1:13-3(d)] Superior Court Of New Jersey BAIL PROGRAM REGISTRATION FORM SECTION I INSURANCE/SURETY COMPANY: Name: _____________________________________ N.A.I.C.#__________________________________ Address: _____________________________________________________________________________________ Street City State Zip Code Telephone: ____________ _________________________ Area Code Number AUTHORIZED (check one) [ ] AGENT [ ] AGENCY [ ] ADMINISTRATOR [ ] MANAGING AGENT: Name: _______________________________________________________________________________________ N.J. Department of Banking and Insurance License #: _______________________________________________________ Exp. Date: _______________ Office Address: _____________________________________________________________________________________________ Street City State Zip Code Telephone: ____________ __________________________ Area Code Number For Agency Registration Only: Name of Agency Administrator________________________________________________________________ (ATTACH A COPY OF THE AGENCY/AGENT/ADMINISTRATOR/MANAGING AGENT LICENSE) Note: Revised form adopted July 28, 2004 to be effective September 1, 2004. Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com SECTION II GUARANTOR TO SATISFY BAIL FORFEITURE JUDGMENTS FOR ABOVELISTED AGENT/AGENCY/ADMINISTRATOR/MANAGING AGENT: The person or entity listed below has provided the insurance/surety company with a guarantee to pay bail forfeiture judgments associated with bail recognizance written by the agent/agency/administrator/managing agent listed in SECTION I: Name: ___ ______________________________________________________________________ N.J. Department of Banking and 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 New Jersey Department of Banking and Insurance. The named agent/agency/administrator/managing agent is authorized to write bail bonds on behalf of that insurance company in New Jersey and is licensed as an insurance producer by the New Jersey Department of Banking and 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 original registration form to: Office of Superior Court Clerk, Bail Program Registration, P.O. Box 971, Trenton, NJ 08625-0971. (THIS FORM MAY BE DUPLICATED) Note: Revised form adopted July 28, 2004 to be effective September 1, 2004. Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com