Application for Contract

I Have Been Employed During the Past Seven Years As Follows:

I Am Pleased to Submit the Following Persons as References:

I hereby certify that in the foregoing declarations, I have stated the truth, without reservation, for the purpose of securing contract and further agree, should this application be accepted, that I will abide by the rules and instructions given me by the Company, directly or through manuals and other forms, and will honestly and faithfully perform the duties required of me on the part of the Company. Authority is hereby granted to any individual firm or corporation, and any financial institution to furnish Roche Surety & Casualty Company, Inc. upon its request with any information concerning the above statement or pertaining to the Undersigned's financial standing, credit or manner of meeting obligations.

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NOTE: A COMPLETE APPLICATION FOR BAIL AGENCY CONTRACT MUST BE COMPLETED FOR EACH PRINCIPAL PARTNER OF THE AGENCY.

Roche Surety & Casualty Company, Inc. is a BBB Accredited Insurance Company in Tampa, FL