Professional Bondsmen Application Template Page 2

Bureau of Securities Regulation

Professional Bondsmen Application

Page 2

DESCRIPTION OF ANY LICENSE ISSUED OR DENIED TO THE APPLICANT BY

THE NEW HAMPSHIRE INSURANCE DEPARTMENT:

DESCRIPTION OF ANY LICENSES ISSUED OR DENIED TO THE APPLICANT

RELATIVE TO THE BAILBOND BUSINESS BY ANY GOVERNMENT AGENCY:

DESCRIPTION OF APPLICANT'S EXPERIENCE IN LAW ENFORCEMENT OR LAW

ENFORCEMENT RELATED OCCUPATION:

10.

A GENERAL POWER OF ATTORNEY FROM A SURETY COMPANY WILL BE

PROVIDED BY:

11.

A FIDELITY BOND WILL BE PROVIDED BY:

12.

IF THE APPLICANT IS NOT A RESIDENT OF NEW HAMPSHIRE, THE SECRETARY

OF STATE HAS BEEN APPOINTED AS "AGENT" FOR SERVICE OF PROCESS.

THE APPLICANT SHALL BE SUBSCRIBED WITH THE SWORN STATEMENT

THAT THE INFORMATION CONTAINED HEREIN IS TRUE.

______________________ APPLICANT

______________________ DATE

SIGNED AND SWORN BEFORE ME TO BE TRUE

______________________

MY COMMISSION EXPIRES

______________________

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