CONSENT RELEASE FORM

I

hereby authorize Express/Atlantic Bail Bonding Company and/or its Agent(s) to receive any criminal history record information pertaining to me which may be in the files of any Federal, State or Local Criminal Justice Agency in the United States or any foreign country. I further authorize Express/ Atlantic Bail Bonding Company and/or its Agent(s) to receive any Department. of Motor Vehicle Records, department of Labor, Social Security Administration or Homeowner Lease/Purchase, Employer, Credit History, Banks/Savings & Loan, finance Company, Attorney/Legal Service, Scholastic and any other information/records pertaining to me. which may be .in the files of any individual, company, and Federal, State, Local or foreign government agencies. This includes, but is not limited to, all federal and state privacy acts, such as Family Education Right and the Privacy Act. I understand that All information obtained will be used -for criminal investigation against myself in the event I do not appear in court and agree that this consent shall be valid until such time as my case has been disposed. In addition to authorizing Express/Atlantic Bail Bonding Company and/or its A.gent(s) to receive said information, any entities releasing said information/records to Express/Atlantic Bail Bonding Company and/or its Agent(s) shall be held harmless from all liabilities by myself.

DOB

RACE

M/F

SSN NUMBER

Driver’s Lie Number

Vehicle Info:

MAKE

MODEL

YEAR

TAG & STATE

STREET ADDRESS

CITY

STATE

ZIP

PRINT FULL NAME

SIGNATURE

DATE

NOTARY