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Notary Public Application - Pennsylvania
| Notary Public Application Form. This is a Pennsylvania form and can be used in Notary Department Of State . |
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NOTARY PUBLIC APPLICATI ON BUREAU OF COMMISSIONS, ELECTIO NS & COMMONWEALTH OF PENNSYLVANIA LEG ISLATION NOTARY DIVISION DEPARTMENT OF STATE 210 NORTH OFFICE BUILDING HARRISBURG , PA. 17120 (717) 787-5280 www.dos.state.pa.us PART I: PLEASE TYPE OR PRINT (See reverse for instructions please write on line above description) NAME (First, M.I., Last) (See Instructions) BIRTH DATE NAME OF EM PL OYER WHERE NOTARY COMMISSION WILL BE USED TYPE OF EMPL OYMENT DATE EMPLOYME NT COMMENC ED (If applicable) STREET ADDRESS OF EMPLOYER CITY STATE ZIP CODE (P.O. Box alone insufficient. If applicable, please include.) COUNTY MUNICIPALITY AREA CODE/TELEPHONE NO. HOME STREET ADDRESS CITY STATE ZIP CODE (P.O. Box alone insufficient. If applicable, please include.) COUNTY MUNICIPALITY AREA CODE/TELEPHONE NO. ALL NOTARY APPLICA NTS FOR AN INITIAL COMMISSION OR HAVE YOU EVER BEEN CONVICTED OF OR ENTERED A PLEA OF REAPPOINTME NT MUST COMPLETE A PREAPPRO VED THREE GUILTY OR NOLO CONTENDERE TO A FELONY OR LESSER HOUR NOTARY PUBLIC EDUCATION COURSE WITHIN SIX MONTHS OFFENSE PRECEDING THE DATE OF THIS APPLICATION? PRIOR TO APPOINTMENT OR REAPPOINTME NT. PLEASE ATTACH A COPY OF YOUR COURSE COM PLETIO N CERT ICATE TO THIS ____ YES ____ NO (Please see General Instructions section.) APPLIC ATION. PLEASE RETAI N YOUR ORIGINAL. If yes, give specific details on a separate sheet of paper; include name of court, DID YOU PERSONALLY CO MPLETE A COURSE? ___YES ____NO IF YES, DATE OF COMPLETI ON________________________________ plea or conviction, sentence and length of probation. (Please be advised that a NO answer will result in application rejection.) HAVE YOU EVER BEEN A NOTARY IN PENNSYLVANIA? HAVE YOU EVER RESIGNED A NOTARY COMM ISSION OR HAD A NOTARY COM MISSION SUSPENDED, REV OKED OR OTHERWISE ____ YES ____ NO DISCIPLINED BY THE COMMONWEALTH OR ANY OTHER STATE/ JURISDICTION PRECEDING THE DATE OF THIS APPLIC ATION? NAME ON PREVIOUS COMMISSIO N: _____________________________ __Yes __No (Please see General Instructions section.) HAVE YOU EVER HAD ANY OTHER DEPT. OF STATE LICENS E EXPIRATI ON DATE: ____________________________________________ SUSPENDED, RE VOKED OR OTHERWISE DISCIPLINED? ____ YES ____ NO If yes, give specific details on a separate sheet of paper. I DECLARE THAT ALL OF THE INFORMATI ON I HAVE PROVIDED OR ATTACHED AS DOCUMENTATION IS TRUE AND CORRECT A ND CONTAINS NO MATERIAL MIS STATEMENT OR OMISSION OF FACT. I UNDERSTAND THAT THE FALSIFI CATION OF ANY STATEMENT OR DOCUMENTAT ION IS SUBJECT TO CRIMINAL P ENALTIES FOR UNSWORN FALSIF ICATION PURSUANT TO 18 Pa.C.S. 4904. SIGNATURE (SHOULD CORRESPOND WITH NAME IN PART I) DATE PART II: REFERENCES: (See instructions) WE THE UNDERSIGNE D, KNOW THE APPLICANT TO BE CAPABLE AND RELIABLE; TO HAVE A GOOD REPUTATION FOR INTEGRITY, SOBRIETY AND TRUTHFULNESS ; AND TO BE QUALIFIED TO HOLD THE OFFICE OF NOTARY PUBLIC. REFERENCE 1 REFERENCE 2 PRINT NAME PRINT NAM E SIGNATURE SIGNATURE NUMBER/STRE ET/CITY/STATE/ZIP NUMBER/STREET/CITY/STATE/ZIP AREA CODE/TELEPHONE NO. AREA CODE/TELEPHONE NO. PART III: TO BE COM PLETED BY PENNSYLV ANIA SENATOR: (See instructions) For Official Use Only *** I HEREBY ENDORSE THE APPLICATION OF THIS APPLICANT WHO IS A RESIDENT OF OR IS EMPLOYED IN MY SENATOR IAL DISTRICT . Serial Number Senator District Date <<<<<<<<<********>>>>>>>>>>>>> 2NOTARY PUBLIC APPLICATION (READ CAREFULLY) General Information: In order to be appointed as a notary public, you must be at least eighteen (18) years of age, be a resident of Pennsylvania or employed within this Commonwealth and pursuant to Act 151 of 2002, have completed a pre-approved three-hour notary education course requirement within the six-month period prior to application for appointment or reappointment on or after July 1, 2003. Please be advised that lack of proof of education will result in application rejection. The Secretary may, for good cause, reject any notary public application subject to the right of appeal. The following persons are not eligible to hold the office of notary public: (1) Any person holding any judicial office in Pennsylvania. (2) Any member of the Congress of the United States, and any person, whether an officer, a subordinate officer or agent holding any office or appointment of profit or trust under the Legislativ Execue,tive, or Judicial Department of the Government of the United States to which a salary,ees or f perquisites are awarded. (3) Any member of the GeneralAssembly of Pennsylvania. Completed applications for reappointment must be filed in this office TWO MONTHS prior to the expiration of the current commission. Renewal applicants should expect AT LEAST ONE MONTH for processing after submitting a completed renewal application to this office. New appointees should allow AT LEAST ONE MONTH for processing after submitting a completed application to this office. If notice of appointment is not received within this time, inquiry should be sent to the address on the front of the applica tion. Filing Fee: Each application must be accompanied by a check or money order for $40.00, made payable to Commonwealth of Pennsylvania, and mailed to 210 North Office Building, Harrisburg, PA 17120. The fee is non-refundable Please. note: the Secretary of the Commonwealth is authorized to revoke the notary public commission of a notary public who issues a personal insufficient funds check to the order of any State agencthey or Commonwealth subject to the right of notice, hearing and adjudication and right of appeal. Oath of Office, Bond, Recording: Upon appointment, the Secretary of the Commonwealth will snd the applie cant an official bond and oath form for execution to the address of the applicants employer or if not applicable, their residence addres s. The applicant should record the commission, executed bond and oath form in the Recorder of Deeds in the county where their office is located. This must be completed withFORTY- FIVE DAYS in after the date of appointment or the commission becomes null and void. General Instructions: This application must be TYPEWRITTEN or PRINTED legibly and all questions must be answered completely. Applications will be accepted only on the form approved for use by the Secretary of the Commonwealth. Theadd ition of advertising to this applicaonti regarding any corporation, association or individual engaged in the business of bonding or supplying notaries public is specificallyibited proh and will cause the application to be rejected. All ans
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