DCJS License # 313965 Ph# 757-604-3002

DCJS License # 313965 Ph# 757-604-3002

Victory Bail Bonds

Application/Contract

Date: ______Court: ______Bail Amount $______

Bond Fee: $______Bond Fee Paid: $______Unpaid Bond Fee: $______

Charge(s): ______AKA or Alias: ______

Defendant’s Full Name: ______Social Security #: ______

Address: ______City: ______State: _____ Zip: ______

Home Phone #: ______Mobile Phone #: ______Email:______

Other Address: ______City: ______State: _____ Zip: ______

Date Of Birth: ______Age:______Height:______Weight:______Scars/Tattoos: ______

Hair Color: ______Eye Color: _____ Race/Nationality: ______Sex:_____ Social Network: ______

Employer: ______Phone #: ______How Long: ______

Employer Address: ______City: ______State: ___ Zip: ______

LIST FAMILY AND/OR FRIENDS AS PERSONAL REFERENCES

Name : ______Address: ______City: ______State___ Zip: ______

Relation: ______Phone ______Mobile # ______

Name : ______Address: ______City: ______State___ Zip: ______

Relation: ______Phone ______Mobile # ______

CO-SIGNER{S} INFORMATION ONLY

Full Name: ______Social Security: ______

Relationship to Defendant: ______Driver's License/ ID #: ______

Home Address: ______City: ______State: ____ Zip: ______

Home Phone #: ______Mobile Phone #:______Email/Social network:______

Birthdate: ______Sex : M or F Type of Car owned: ______License Plate #: ______

Employer: ______Phone #: ______Other Phone #: ______

Employer Address: ______City: ______State: ___ Zip: ______

Supervisor: ______Department/Position: ______How Long:_____

I (We), the cosigner(s), understand that I am (we are) responsible for the appearance of the person named above (the defendant) to be in the respective courts(s) on any given date(s) issued by the court(s). If this person does not appear in court, I (we) will be responsible for the entire amount of the bond and all expenses (travel fees, bail enforcement fees, attorney costs, court cost, etc.) that may be incurred in the process and re-arrest of the named person. I (We), the co-signers, and the defendant, also understand that we will notify Victory Bail Bonds immediately of any changes to the phone numbers and/or addresses listed above. For the value received, the undersigned defendant and cosigner(s), jointly and separately, promise and agree to pay Free Bird Bail Bonds for any loss they suffer by the failure of the defendant to fulfill all of the conditions of this bond and/or his/her release.

______Date: ______Date: ______Date _____

Co-Signer Signature Co-Signer Signature Defendant Signature

Receipt For Payment Date ______

Victory Bail Bonds has received $______, ______Dollars

For Bail Bond Payment from: ______. Cash Credit Other

Bondsman’s Signature: ______.