Bail Bondsman - Additional License Category Application Form Page 2
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1
2Affirmation
________ (initial) I, the undersigned, certify that all information contained on this application is true and correct to the best of
my knowledge and I have not omitted any pertinent information.
________ (initial) I understand that any misrepresentation, falsification or omission of pertinent information may be cause
for denial of my application.
________ (initial) I understand that any misrepresentation, falsification or omission of pertinent information may be
forwarded to the Commonwealth’s Attorney Office for criminal prosecution.
________ (initial) I understand that any misrepresentation, falsification or omission of pertinent information may result in
criminal charges, including but not limited to feloniously forging and uttering a public document in violation
of Va. Code § 18.2-168.
________ (initial) I understand that I am responsible for maintaining full compliance with the Virginia Code and applicable
regulations relating to Surety and Property Bail Bondsmen and Bail Enforcement Agents.
________ (initial) I hereby give consent and authorize the Virginia State Police and the Federal Bureau of Investigations to
process my fingerprints for a criminal history records check and report the results of such record to the
Virginia Department of Criminal Justice Services (DCJS). I authorize the Virginia State Police to archive
my fingerprints for the purpose of reporting any future criminal history information. I fully understand that if
I am arrested this information may be reported to DCJS.
Print Name:
______________________________________________________________________________
_________________________________________________
__________
Signature Required:
Date:
mm/dd/yy
APPLICATION MUST BE NOTARIZED
STATE OF VIRGINIA
CITY/COUNTY OF _
___________________________________________, to wit:
The foregoing application was acknowledged before me this
________ day of
_______________, 20
___
by
_____________________________________________________.
My commission expires:
Notary Registration Number:
______________
Notary Public
All fees are non-refundable. Applications received without payment will be returned.
Submit a check or money order payable to the TREASURER OF VIRGINIA,
or pay by credit card using the
Credit Card form
available at
—
this form must be included with your application package when paying by credit card.
05/2014
Page 2 of 2
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