Defendant Authorization Form450 Church Street ∙ HARTFORD CT 06120 ∙ (860) 727-9121Download Here or fill out the form below. Location:*HARTFORD LOCATION 90 Brainard Road, Suite 203, Hartford, CT 06114BRIDGEPORT LOCATION 2929 Fairfield Ave, Bridgeport, CT 06605NEW HAVEN LOCATION 857 Whalley Avenue New Haven, CT 06515Defendant Name:* Name Of Bail Agent:* Name Of Bail Bond Company* By signing my name below, on this date, I authorize the bail bond agent named herein to execute bail bonds on behalf of myself or the person I represent. I understand that this will begin the bail bond process.NOTE: If I am signing this form as a duty designated representative of the defendant, I certify that I am at least 18 years of age and that I have full permission of the defendant to enter into this agreement.Do You Agree To Our Electronic Signature Terms?*I AgreeYou consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any agreement, acknowledgement, consent, terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Afford-A-Bail Bail Bonds. You understand and agree that your e-Signature executed in conjunction with the electronic submission of your application shall be legally binding and such transaction shall be considered authorized by you.Signature of Defendant or Authorized Representative*Date* MM slash DD slash YYYY Name of Authorized Representative (if applicable) Date MM slash DD slash YYYY bail agent license number signature of bail agent
