Sales Tax Bond Application

Sales Tax Bond

Sales Tax Bond Application for MSB Surety Bonds.
Business Name
Sales Tax Number
Employer Identification Number (EIN) From IRS
Contact Name

First NameLast Name
Title
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Business Address
City
State
Zip Code
Business Type
Years in Business
Bond Amount
Is this bond required by the Comptroller of Public Accounts?
Effective Date

MonthDayYear
Date
Prior Surety Company
Current Bond Status
Bankruptcy History
Claims History
1. Owner Name
Owner Address
Owner Date of Birth
Owner Social Security Number
Ownership Percentage
If there is more than one owner, please enter additional owner's information on this section. Name, Address, DOB, SSN, & Ownership Percentage.
Applicant Certification
By signing below, I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge and belief. I understand that any omission, misrepresentation, or false statement may affect the processing of my application, insurance quote, policy, or bond request.

I acknowledge that MSB Insurance Group, LLC and its insurance carriers, brokers, or surety companies may rely on the information I have provided in evaluating my request.

As part of the application process, a credit score may be obtained. Access to our credit score provider(s) system is for authorized users and only for permissible purpose access. Unauthorized access is prohibited under the Fair Credit Reporting Act and punishable by $2500 and/or one (1) year in Federal prison per occurrence.

Electronic Signature Certification

By typing my name, drawing my signature, or electronically signing this form, I agree that my electronic signature has the same legal effect as my handwritten signature and that I certify the information provided above is true and correct to the best of my knowledge.
Signature
Should be Empty: