Defendant Application

Fill out the form completely. False information may disqualify your application.

NOTE: False information, omissions or misrepresentation of facts called for in this application may disqualify your application. Fill out form in its entirety. * indicates required fields.

Questions? Call us at (919) 834-2288 — available 24/7.

DEFENDANT PERSONAL INFORMATION

First Name *

Middle Name

Last Name *

Date of Birth *

Social Security Number *

Sex *

Race *

Height *

Weight (lbs) *

Eye Color *

Hair Color *

CURRENT ADDRESS

Street Address *

City *

State *

ZIP Code *

Home Phone

Cell Phone *

Email Address

Residence Type *

Years at Current Address *

EMPLOYMENT INFORMATION

Employer Name

Occupation / Job Title

Employer Street Address

Employer City

Employer State

Employer Phone

Years Employed

Monthly Income

ARREST INFORMATION

County of Arrest *

Date of Arrest *

Charge Description *

Bond Amount *

Case / File Number

Court Date

Court Location / Courthouse

EMERGENCY CONTACT

Contact Name *

Relationship *

Contact Phone *

Contact Address *

ADDITIONAL INFORMATION

Prior Arrests? *

Prior Felony Convictions? *

Additional Information / Comments

By submitting this form you authorize Golder Bail Bonds Inc. to release all credit data necessary to complete this process.

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