A credit check may be required for this bond. Listed prices are the lowest prices available for individuals with good credit. Negative credit may result in a premium higher than that listed. If a higher premium is required, we will contact you within one business day and seek your approval before proceeding. If you choose to cancel your order because of a higher premium, you will not be charged.Please Complete and Print, then fax form to (619)223-3441 or email to simplebond@aol.com Term $50,000 Motor Vehicle Dealer Bond One-year coverage - $800.00 - $1500 depending upon the personal credit strength of the applicant $10,000 Wholesale Only Dealer Bond One-year coverage - $250.00 $10,000 Motorcycle Only Dealer Bond One-year coverage - $250.00 Type of Business Sole Proprietorship Partnership Corporation LLC Number of Partners If you selected Partnership above, please select the number of partners. Otherwise, set this value to zero. 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Real Estate Do you own real estate? No Yes Name to appear on bond Print the name exactly as it is to appear on the bond. This may be the same as your full name, a DBA, a corporation, etc. Name of person who will sign for this bond If the name appearing on the bond is a business or corporation, this must be the name of the owner or president. If the name appearing on the bond is an individual, then the name is the same. Same as name appearing on bond. Social Security Number of person who will sign for this bond Reference Code: Teresa Stewart-Golden State Ed Services If you do not have a Simplebond Reference Code, leave this blank. Requested effective date Leave this blank if you wish your bond to become effective the same day it is issued. You may request to have your bond become effective at any date in the future, or up to 30 days in the past. 1 2 3 4 5 6 7 8 9 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2003 2004 2005 2006 2007 2008 Mailing Address Simplebond will mail the bond to this address. Address Line 1 Address Line 2 City State Zip code Business Mailing Address Same as mailing address. Address Line 1 Address Line 2 City State Zip code Your phone number Area Phone Number Extension Your fax number Area Phone Number Extension Your e-mail address