HAMPTON ROADS BONDING
1080 Laskin Road, Suite 204
Virginia Beach, Virginia 23451
Phone (757) 491-1100/Fax (757) 491-3134

SURETY APPLICATION


General Information

Contractor: _____________________________             Type: ____________________________
                             (as name appears on license)                                           (Corporation, Partnership. Proprietorship)

Address: _______________________________             Phone: ___________________________
              _______________________________


Date Business Formed: _______   Date / State Incorporated: _______   Tax I.D. No.: __________


Type of Work Performed :________________              Percent Subcontracted: _______________ 


Geographic Area Served: ________________                Trades Subcontracted: ________________


 Is the company, its owners or officers connected with other companies, partnerships or ventures?:    Yes  ___    No ___

If yes, list them and describe relationship:    
_______________________________________________
Owners, Oficers And Their Spouses:                     ATTACH RESUMES
Name / Spouse
Age
Title
% Ownership
Social Security Nuber(s)
1.                                                                                                                                  /
2.                                                                                                                                 /
3.                                                                                                                                 /
4.                                                                                                                                 /
5.                                                                                                                                 /

How long in business under present ownership/management?:   ____  Is there key man life insurance?:  Yes  __    No __

Is there a buy/sell agreement or job completion plan?                Y/N:   ____                          On Whom:  _____________

**If yes please provide documentation:                                                                                   Amount:  _______________

What is the largest amount of uncompleted work on hand at any one time in the past?:               $________________

                                                                             No. of jobs:  ______________                 Year:  _____________

List The Five Largest Contracts Completed In The Past Five Years:
Owner (incl. Contact Person)
Phone No.
Job
Contract Price
Profit
Compl. Date
1.                                                                                                                          
2.                                                                                                                              
3.                                                                                                                      
4.                                                                                                                             
5.                                                                                                                             

Has the company (or an officer/owner) ever failed to complete a contract?:  Yes  __    No __

Caused a surety a loss?:  Yes  __    No __

**If so, explain: _____________________________________________                                                                                 

List The Three Largest Contracts Currently In Progress:
Owner (incl. Contact Person)
Phone No.
Job
Contract Price
Est. Profit
Est. Compl.
1.                                                                                                                          
2.                                                                                                                              
3.                                                                                                                      
List Three Architects That You Have Worked With In The Past Three Years:
Owner (incl. Contact Person)
Phone No.
Job
Contract Price
Profit
Compl. Date
1.                                                                                                                          
2.                                                                                                                              
3.                                                                                                                      
List Prior Bonding Companies And Reason For Change::
Name
Reason For Change
1.
2.                                                                                                                            
Has the company, any of its owners and officers, ever been in bankruptcy or receivership? Yes_ No_
If yes, please explain and identify bankruptcy proceeding by date tried, court and case number:

Are any liens filed against the company, or is the company, an owner or officer, involved in
litigation?  Yes__  No__
If yes, please explain and identify litigation by caption, case number , court, etc.:


List Major Suppliers:
Name
Material/Service Provided
Complete Address
Phone No.
1.                                                                                                                          
2.                                                                                                                              
3.                                                                                                                      
4.                                                                                                                             
5.                                                                                                                             
Accounting:
When Is Your Fiscal Year End?
When Is Your Tax Year End?
On Which Method Are Taxes Paid?
Cash _____    Accrual ______
Compl. Contract ______    % ______
Who Prepares Your Tax Returns?

CPA __  Public Accountant__  Tax Service__  Internal __ 		Name Of CPA Firm, Contact And Phone NO..
__________________________________________
__________________________________________
Who Prepares Your Financial Statements?
CPA __  Public Accountant__  Tax Service__  Internal __ 		Same CPA For Tax Returns And Financial Statements? Yes ___  No ___
On What Method Are The Statements Prepared?
%__  Accrual__  Cash__  Other __
 How Often? Does Your Office Have A Full Time Accountant?     Yes ___  No ___
Describe Your Job Cost Record Keeping System:
Banking:
Name Of Bank:   __________________________
Address:
Loan Officer:  __________________________
Phone Number:
On What Method Are The Statements Prepared?
%__  Accrual__  Cash__  Other __
 How Often? Does Your Office Have A Full Time Accountant?     Yes ___  No ___
Amount Of Line Of Credit:
EXPIRATION DATE:
 How Secured? Amount In Use $
Checking / SavingsAccount Number(s):
ATTACH A TERMS AND CONDITIONS LETTER SIGNED BY THE LOAN OFFICER
I / WE AUTHORIZE THE SURETY TO INVESTIGATE THE INFORMATION PROVIDED ON THIS APPLICATION. WE UNDERSTAND THAT INQUIRIES WILL BE MADE TO VERIFY PAST PERFORMANCE AND CREDIT HISTORY, AND THAT SURETY WILL ORDER CREDIT REPORTS ON THE COMPANY, ITS OWNERS, OFFICERS AND THEIR SPOUSES.
THIS APPLICATION HAS BEEN GIVEN TO INDUCE SURETY TO EXTEND CREDIT, AND THE OFFICER SIGNING BELOW ATTESTS TO THE TRUE AND ACCURATE REPRESENTATIONS MADE HEREIN.
SIGNED THIS ______________   DAY OF ______________,   20___________.
SIGNATURE: ___________________    PRINTED NAME & TITLE: ___________________
AGENT: _________________________                         DATE:  _________________________