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Application for Liable Bail Agent

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 Notice to Applicant: Federal Law - VIOLENT CRIME CONTROL AND LAW ENFORCEMENT ACT OF 1994, 18 U.S.C SECTION 1033 prohibits certain activities by or affecting persons engaged, or proposing to become engaged, in the business of insurance:

 

(e)(1)(A) Any individual who has been convicted of any criminal felony involving dishonesty or breach of trust, or has been convicted of an offense under this section, and who willfully engages in the business of insurance whose activities affect interstate commerce or participates in such business shall be fined as provided in this title or imprisoned not more than 5 years, or both.

(B)  Any individual who is engaged in the business of insurance whose activities affect interstate commerce and who willfully permits the participation described in subparagraph (A) shall be fined as a provided in this title or imprisoned not more than 5 years or both.

(e)(2) A person described in paragraph (1)(A) may engage in the business of insurance or participation in such business if such person has the written consent of any regulatory official authorized to regulate 
the insurer, which consent specifically refers to 18 U.S.C Sections 1033 and 1034.

You must answer every question on the application. If a question does not apply, indicate N/A in the space provided for the answer. Your answers are not limited to the space provided on the Application. Attach additional pages as needed. First Financial Surety Services, will not process incomplete applications. Additional information may be requested.

Application: Job Application

Employer  Information

Section I - Applicant Information

U.S Citizen:

Do you have a current in-force bail bond license?

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Are you engaged in any other business?

Have you ever-declared bankruptcy?

Section II- Applicant Education

Section II- Applicant Criminal and Regulatory History

Has any regulatory agency ever taken any disciplinary action against you, your business, or any business in which you have been directly connected? Disciplinary and Regulatory actions include but are not limited to license suspension, revocation, and/or a monetary fine.

Have you ever had your bail contract canceled by a surety or general agent?

Have you ever been arrested, charged, convicted of, or plead nolo conterdere (no contest) to a felony, gross misdemeanor, or a misdemeanor involving moral turpitude or currently have pending any misdemeanor or felony charges against you? (Misdemeanor does not mean traffic minor traffic violations.)

Re: Title 28 Privacy Act, Freedom of Information Act, Title 6 Fair Credit Reporting Public Law 91-508 

To ensure full compliance with the Title 28 Privacy Act, Freedom of Information Act, Title 6 Fair Credit Reporting Public Law 91-508, and to facilitate easy access to all information necessary, please read and sign this form. 

I understand that investigative inquiries are to be made on myself including consumer, criminal, driving, and other reports. These reports will include information as to my character, work habits, performance, and experience along with reasons for termination of past employment from previous employers. I also understand that you will be requesting information from various federal, state, and other agencies which maintain records concerning any past activities relating to my credit, criminal, civil, and other experiences as well as claims involving me in the field of insurance. 

 

I authorize, without reservation, any party or agency contacted to front us the above-mentioned information about me to you. 

 

I have a right to make a written request within a reasonable period of time to receive additional information about the nature and scope of this investigation. 

 

I hereby consent to your obtaining the above information and agree that, if appointed with you, such information you obtained along with information relating to my performance with you will be accessible through you by future insurance companies to which I might apply. 

 

I certify that each statement there and made is full, true, and correct to the best of my knowledge. 

 

I agree that pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 18 United States Code Sections 1033, 1034, I will notify First Financial Surety in writing, within 30 days of my being convicted of a felony. 

*REMINDER: You must report any change of address to First Financial Surety as well as your state Department of Insurance, within 30 days of the change of address.*

Thank you for your submission!

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