Bail Bondsman Registration Form - City Of Choctaw
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Cash
BAIL BONDSMAN REGISTRATION
□ __________
Check
□ __________
Credit Card
Received $ 75.00
Choctaw Registration #____________________
Date: _______________________
Receipt No. __________________
The following documents are required for registration or changes to a current registration with the
City of Choctaw.
1. This completed registration form (Fill in every space. Incomplete form will not be recognized).
2. Proof of registration with Oklahoma County.
3. Current insurance license / card.
4. Letter of Good Standing with the Oklahoma Insurance Commission.
5. Power of Attorney from Agent or Underwriter.
6. Attach a list of all recovery agents.
PLEASE PRINT OR TYPE
Bonding Company Name:
Company Owner’s Legal Name:
Bondsman Name:
Please Print
Email Address:
OK License #________________________ Expiration Date:
Bonding Co Mailing Address:
Street
City
State
Zip Code
Bonding Co Physical Address:
Street
City
State
Zip Code
Phone Number: (_____)-______-_________ Fax Number: (_____)-______-
Cell Number: (_____)-______-_________ Emergency Number: (_____)-______-
Professional, Agent or Underwriter Name:
Mailing Address:
Street
City
State
Zip Code
Physical Address:
Street
City
State
Zip Code
Phone Number: (_____)-______-_________ Fax Number: (_____)-______-
Cell Number: (_____)-______-_________ Emergency Number: (_____)-______-
I understand that failure to comply with applicable laws may result in loss of registration and/or fines and
that this registration MUST BE RENEWED YEARLY BY JUNE 30TH. I have submitted the required
paperwork, including a copy of my County License, Letter of Good Standing, POA from Agent/
Underwriter and current insurance.
Date: ________________
Bondsman’s Signature:
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