Notary Public Application Form

Notary Public Application Form

WHEREAS

WHEREAS, the Applicant seeks appointment and commission as a Notary Public in the appointing jurisdiction and submits this application for consideration by the appointing authority; and

WHEREAS, by submitting this form the Applicant consents to the review of background records and the filing of any required bond, oath, and other documentation as required by law.

Applicant Information

Full Legal Name

Residence Address

Mailing Address (if different)

County of Residence:

Telephone

Email

Date of Birth: Day Month Year

Commission and Bond Information

Requested Commission Start Date:   Requested Commission End Date:

Surety Bond

Bond Amount: $    Bond Number:

Bond Effective Date:

Employment / Business Information

Employer / Business Name

Business Address

Background and Eligibility

Have you ever been convicted of a felony, been subject to a conviction that would disqualify you from commission, or had a notarial commission revoked in any jurisdiction?   Yes    No

Are there any pending criminal charges or disciplinary proceedings against you?   Yes    No

I certify that the information provided on this application is true and complete to the best of my knowledge and I understand that false statements may subject me to denial, revocation, or other disciplinary action, and that willful falsification may be punishable by law.

Authorization and Oath

By signing below, the Applicant swears or affirms under penalty of perjury that the statements made in this application are true, and authorizes any appointing authority to obtain criminal history records, to receive fingerprint information, and to make any other inquiries necessary to determine eligibility.

Applicant acknowledges obligation to maintain an official seal and to notify the appointing authority in writing of any change in name or residence address within the time period required by law.

Attachments and Fees

Application Fee: $

Payment Method: Check Money Order Credit Card

Fingerprint Card Submitted: Yes No

Scope of Duties Acknowledgment

Certification and Signature

I, the undersigned Applicant, do solemnly swear (or affirm) that I will support the Constitution of the appointing jurisdiction, that I will faithfully discharge the duties of Notary Public according to law, and that I will well and truly perform all acts required of me as a Notary Public during the term of my commission.

For Official Use Only

Application Received By (Official):

Date Received:

Official Notes

Certification: I certify under penalty of perjury that this application was examined and the required documentation is attached for filing as indicated above.

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