Machaen Enterprises, Inc.

Department of Transportation

Issuer of bonds to Department of Transportation

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Department of Transportation Application
Department of Transportation Check list

Machaen Enterprises, Inc.

LICENSE/ PERMIT/ MISCELLANEOUS

BOND INFORMATION

TYPE OF BOND

AMOUNT OF BOND:

EFFECTIVE DATE

OBLIGEE NAME:

OBLIGEE ADDRESS:

EXPIRATION DATE: (IF OTHER THAN ONE YEAR)

BUSINESS INFORMATION

COMPANY NAME

PHONE #

FAX #

COMPANY ADDRESS

CITY

STATE

ZIP CODE:

COMPANY

NATURE OF BUSINESS

TYPE

OF OWNERS, PARTNERS OR MEMBERS

HOG LONG IN BUSINESS?

PREVIOUS BONDING COMPANY

REASON FOR CHANGING BONDING COMPANY:

EMAIL ADDRESS:

PERSONAL INFORMATION

APPLICANTS NAME:

SOCIAL SECURITY #

DATE OF BIRTH #

SPOUSE'S NAME:

SOCIAL SECURITY #:

DATE OF BIRTH:

RESIDENCE ADDRESS:

CITY:

STATE:

ZIP CODE:

ESTIMATED PERSONAL NET WORTH:

ARE YOU THE TRUSTEE, TRUSTOR OR BENEFICIARY OF ANY TRUST

EVER DECLARED BANKRUPTCY?

PENDING OR PRIOR IRS LIENS?

ANY LAWSUITS PENDING AGAINST YOU?

EVER DECLINED FOR BONDING PREVIOUSLY?

PERSONAL INFORMATION

CO-APPLICANTS NAME:

SOCIAL SECURITY #

DATE OF BIRTH #

SPOUSE'S NAME:

SOCIAL SECURITY #:

DATE OF BIRTH:

RESIDENCE ADDRESS:

CITY:

STATE:

ZIP CODE:

ESTIMATED PERSONAL NET WORTH:

ARE YOU THE TRUSTEE, TRUSTOR OR BENEFICIARY OF ANY TRUST

EVER DECLARED BANKRUPTCY?

PENDING OR PRIOR IRS LIENS?

ANY LAWSUITS PENDING AGAINST YOU?

EVER DECLINED FOR BONDING PREVIOUSLY?

I agree that any electronic signatures (including facsimile signatures) utilized in connection with the execution of this document shall be considered originals and be fully binding and enforceable. Further, the use of any electronic signature by a party shall be evidence of that party's intent to be bound to the terms of such document. The parties agree that they shall not raise any defense (statutory or otherwise) to the enforceability of this document based upon the fact an electronic signature has been used.

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Machaen Enterprises, Inc.

Surety & Fidelity Bond Agency

DOCUMENT CHECK LIST FOR DEPARTMENT OF TRANSPORTATION

THE FOLLOWING ARE THE DOCUMENTS REQUIRED FOR THE RENEWAL OR PROCESSING OF YOUR SURETY BOND:

LATEST COMPANY FINANCIAL STATEMENTS

All Services

Airlines Reporting Corporation

Money Transmitters

Department of Transportation

Health Club

Used Car Dealer

Driving School

Financial Guarantee

Public Official (Notary)

Utility

Federal Maritime Commission

222 Bruce Reynolds Blvd., Suite 460 Fort Lee, NJ 07024

(201) 327-8400

support@machaenenterprises.com