Enrollee Monitoring Application

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Bondsman*

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Agreement Date*

Enrollee's Full Name*

Guarantor's Full Name*

Please Choose a Device*

Daily Rate*

Number of Days to Charge*

Enrollment Fee*

Please enter a number greater than or equal to 0.

Daily Rate Total*

Replacement Fee*

Please enter a number greater than or equal to 0.

Transaction Fee*

Total Owed Today:

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Total Owed Today*

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Trans Fee*

Add Transaction Fee

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Yes