CB&MS License Bond Application
P.O. Box 681 Bothell, WA 98041 | (206) 361-9693
Business Name (Exactly as shown on license)
Business Type
Sole Owner
Corporation
Partnership
LLC
Other
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
Please enter a valid phone number.
Email
example@example.com
Bond Amount
Obligee
Type of Work
License Number
Number of years you have owned this business
Number of years experience
Value of Primary Residence
Balance of Mortgage
Have you (or any other partner or officer):
No
Yes
Ever failed in business?
Ever declared bankruptcy?
Ever had a bond cancelled?
Ever been convicted of a felony?
Ever had prior or pending liens?
Ever had license suspended, revoked or denied?
Ever had claims against your bond?
Ever been declined by another bonding company?
If you answered yes to any of the above, attach explanation.
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Complete the following information on each owner or stockholder, including yourself.
Name
First Name
Last Name
Social Security Number
Percent of Ownership
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Is there another owner or stockholder?
No
Yes
Name
First Name
Last Name
Social Security Number
Percent of Ownership
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Acknowledgement
Any person who knowingly and with intent to defraud a surety company or any other person files an application for a surety bond contain any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act and may be subject to civil and/or criminal penalties.
Signed this
Date
Name of Owner/Partner/Officer
First Name
Last Name
Title
Signature of Owner/Partner/Officer
Name of Owner/Partner/Officer
First Name
Last Name
Title
Signature of Owner/Partner/Officer
Submit
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