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Form Bb-692-002 - Application For Licensure As A Bail Bond Agency Or Bail Bond Agency Branch Office 1999 Page 2

APPLICANT PERSONAL DATA

1. Have you been convicted of a crime, misdemeanor or felony in this state, any other state, by the federal government, or

any other jurisdiction within the past ten years?

Yes

2. Is there a criminal complaint, accusation, or information presently pending against you or are you currently under indictment

in this state, any other state, by the federal government, or any other jurisdiction?

Yes

3. Has any professional or occupational license, certification, or permit held by you been fined, suspended, revoked, refused

or denied in this state, any other state, by the federal government or any other jurisdiction?

Yes

4. Have you ever had a civil court order, verdict, or judgement entered against you in any court of competent jurisdiction in

this state, any other state, by the federal government, or any other jurisdiction?

Yes

Please attach a letter of explanation for any affirmative answers to the above questions, including charges(s), date

of conviction, civil judgement or order, county jurisdiction, state, and disposition of charges.

AFFIDAVIT

I, __________________________________________________________, being first duly sworn, depose and say that I

PRINT NAME

am the qualified agent and authorized to sign for the sole proprietorship, partnership or corporation as indicated in this

application. I have carefully read the questions in the foregoing application and have answered them completely, and

pursuant to RCW 9A.72.085 I declare under penalty of perjury under the law of the state of Washington that my answers

and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby

agree that such act shall constitute cause for the denial, suspension or revocation of the license to practice as a bail bond

agency, bail bond agency branch office, or qualified bail bond agent in the state of Washington.

Signature of qualified agent ________________________________________________ Date____________________

City ___________________________________________________________________ State____________________

UPON FILING, THIS APPLICATION BECOMES A PUBLIC RECORD AND IS SUBJECT TO

PUBLIC DISCLOSURE PROVISIONS PURSUANT TO RCW 42.17.

BB-692-002 BAIL BOND AGENCY APP. (R/11/99)M/W Page 3 of 4

Form Bb-692-002 - Application For Licensure As A Bail Bond Agency Or Bail Bond Agency Branch Office 1999 Page 2