I am providing this information for the specific purpose of applying for appointment as a Bail Agent authorized to post Surety Bail Bonds, in the Courts of my licensed state(s), on behalf of Universal Fire and Casualty Insurance Company. I hereby certify that I am making application to be insurance licensed, or that I am currently licensed for this line of business and that license is compliant and in good standing with all Department of Insurance licensing rules and regulations. I further certify that all information submitted in this application and attachments is true and complete. Should I be appointed, I understand that it is my obligation to keep this information accurate and up-to-date, with Universal Fire & Casualty Insurance Company, and its affiliates. This includes any notification I receive directly from a federal, state or court official concerning the censure, suspension or revocation of my bail license and/or writing privileges. I understand that I am also obligated to make immediate and full disclosure concerning any criminal or misdemeanor charges that should be brought against me, during the course of my company appointment. I understand that investigative inquiries can be conducted now or anytime during the tenure of this appointment. I acknowledge my right to make a reasonable written request to Universal Fire and Casualty Insurance Company to obtain information on the nature and scope of such an investigation. I hereby authorize Universal Fire and Casualty Insurance Company and its affiliates to obtain information from any and all relevant sources with regard to my financial and fiduciary responsibilities (including any credit reporting agency), past and present employment, business practices, license and appointment histories, insurance transactions, real estate and property holdings, criminal and judicial records, private business records including medical reports and any other information that may reflect upon my reliability, character, work habits, ethics and ability to effectively represent Universal Fire and Casualty Insurance Company and its affiliates. I authorize Universal Fire and Casualty Insurance Company and its representatives to share this information with other individuals or companies who are participating in my appointment process or tenure, or future appointment in the insurance industry. I hereby authorize any person or entity requested to furnish the above information to Universal Fire and Casualty Insurance Company and its affiliated representatives, upon the presentation of this document in its original form, in a photocopy or facsimile version.