WILLIAMS
P.O. Box 4376    Davenport, Iowa 52808-43760
(563) 326-5366    FAX (563) 326-2103

Please print, sign and fax this authorization to 563-326-2103
APPLICATION FOR BAIL BOND AGENCY
(please type or print)
 
Name ______________________________________________________________________

Home Address ______________________________________________________________

City _______________________ State __________________  Zip ________________

Home Phone (________) _____________________  Date of Birth ________________

Social Security #  ________________________  Bus. Address _________________

City _______________________ State __________________  Zip ________________

Bus. Phone (________) _____________________  Marital Status _______________

Name of Spouse ____________________________________________________________

Are you presently in the Bail Bond business? ______________________________

If so, how long? ___________________________  License # ___________________

What volume of business are you now writing? ______________________________

Please submit three references:

	NAME			ADDRESS				PHONE		

1. ___________________	____________________________	___________________

2. ___________________	____________________________	___________________

3. ___________________	____________________________	___________________
RE: TITLE 28 PRIVACY ACT, FREEDOM OF INFORMATION ACT, TITLE 6 FAIR CREDIT REPORTING ACT, PUBLIC LAW 91-508
In connection with my application for bail bond agency/bail bond agent with Williams, I understand that investigative inquires 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. Further, I understand that you will be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to credit, criminal, civil and other experiences as well as claims involving me in the files of insurance companies.

I authorize, without reservation, any party or agency contacted by Williams to furnish the above mentioned information.

I hereby consent to your obtaining the above information from US Datalink, National Credit Information Network (W.D.I.A), or other source deemed necessary, and agree that such information you obtain, and my experience with you if I am contracted and appointed will be accessible through you by future companies to which I might apply.

Date:___________________ Signature:__________________________________