IN THE DISTRICT COURT OF _____________________ COUNTY STATE OF OKLAHOMA Re: Application of ) ) _________________________________________ ) For License as a Statewide Private Process Server ) Case No. Application Applicant's Full Name Type of Application Initial Gender Renewal Female Male Residence Address (Physical Address Only ­ Post Office Box is Unacceptable) City State Zip How long at this address? Residence Phone Business Address City State Zip Business Phone Date of Birth Hair Color Social Security Number Height Eye Color Weight Maiden or any other name(s) used Driver's License Number Qualifications & Background Information Have you ever held a Private Process If yes, give the Oklahoma county in which the license was issued, the Server License issued by the State of case number, and the issue date and expiration date of the license: Oklahoma (Statewide or County)? Yes No. Have you ever held a Private Process If yes, give the state, county, case number or license number, issue date Server License issued by any other and expiration date of license: state? Yes No. 1. Have you ever been convicted of a felony? Yes No. 2. Have you been convicted of a misdemeanor within the last five (5) years? (Minor traffic violations need not be disclosed, but all other offenses, including DUI, must be.) Yes No. Yes No. Yes No. Yes No. Yes No. 3. Are there any criminal charges now pending against you in Oklahoma, in any other state, or in any other jurisdiction? 4. Have you ever had a professional license or certificate of any kind suspended, revoked, surrendered, disciplined, refused or denied? 5. Is there any investigation or disciplinary action pending against a professional license or certificate issued to you in Oklahoma, any other state, or any other jurisdiction? 6. In the past year, have you been denied a Private Process Server License by the State of Oklahoma for failure to meet the necessary license qualifications? If yes, applicant is prohibited from reapplying for a period of one (1) year, 12 O.S. § 158.1. If you answered "yes" to any of the above six (6) questions, attach a written explanation providing details (include date of occurrence, jurisdiction, charge or offense, a complete description of the circumstances leading to the charge or action taken, and the disposition or status of the matter). American LegalNet, Inc. www.FormsWorkFlow.com Private Process Server License Application, Page 2 of 2 Applicant's Full Name Previous Residence Address(es) for the past six (6) months (if any, other than above): Affidavit of Residency (both requirements must be met to qualify for a license): I have been a resident of the State of Oklahoma for a period of not less than six (6) months I have been a resident of the county or judicial administrative district in which this application is submitted for a period of not less than thirty (30) days. Affidavit of Citizenship (check one): I am a United States Citizen. I am a qualified alien under the Federal Immigration and Nationality Act and am lawfully present in the United States. (provide supporting documentation) Supplied herewith are (check all that apply): Original application fee of One-Hundred-Fifty Dollars ($150.00) and all other fees and court costs as provided by law. Renewal of original application fee of Fifteen Dollars ($15.00) and all other fees and court costs as provided by law. Photograph Applicant hereby applies for a license as a private process server to serve process issued in civil cases for service within the State of Oklahoma, in accordance with the provisions of 12 O.S. § 158.1. THIS APPLICATION IS A SWORN STATEMENT. I hereby swear or affirm, under penalty of perjury, that I am eighteen (18) years of age of age or older, possessed of good moral character, and believe myself to be ethically and mentally fit to act as a private process server. I understand that willful omission or misrepresentation of any fact required to be disclosed on this application or any accompanying statement is grounds for denial or revocation of my private process server license. I further swear or affirm that all information furnished herein is true and correct to the best of my knowledge. I acknowledge and understand that under the laws of the State of Oklahoma, Title 21, Section 491, a person who makes a false assertion in a sworn affidavit is guilty of perjury, and a person who falsely states that he or she is a United States citizen or a qualified alien may be subject to both federal and state criminal sanctions. Once found qualified for the license sought hereby, I will execute the required statutory bond for faithful performance of my duties and will abide by all the provisions of the applicable law. Applicant's Signature Subscribed and sworn to before me, the undersigned, this County of , State of My Commission Expires: day of . Date , 20 in the Court Clerk or Notary BY Private Process Server License Application, Effective Jan. 1, 2013. American LegalNet, Inc. www.FormsWorkFlow.com