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Notary Public Application Last Name: Print Reset Save Enclose $10 fee payable to Secretary of State. Return completed form to: Secretary of State Index Department, 111 E. Monroe, Springfield, IL 62756. Business Address (P.O. Box not acceptable): Street: Name of Employer: Business Phone: Email Address: Current Home Address (P.O. Box not acceptable): Street: First Name: Middle Name or Initial: Jesse White -- Illinois Secretary of State City: Date of Birth: Driver's License or State Identification Card Number (attach a photocopy): State: ZIP Code: Home Phone: City: Current Expiration Date: _________ Commission Number: ____________ County of Residence: State: Applying for: I New Commission I Renewal of Commission ZIP Code: Has your name, address or county changed since your last commission? If, yes, give previous name, address and/or county: _______________________________________________________________________________________ I Yes I No NOTARY PUBLIC BOND Witnessed and Affirmed this ____________ day of _____________________, 20 _________________ Notary Public Signature:_______________________________________________________________ Signature of Applicant as Printed Above: ____________________________________________________________________ Printed Name as you want Commissioned: _________________________________________________________________ I do solemnly affirm, under the penalty of perjury, that the answers to all statements on this application are true, complete and correct; that I have carefully read the notary law of the State of Illinois; and that if appointed and commissioned as a notary public, I will perform faithfully, to the best of my ability, all notarial acts in accordance with the law. Further, my signature below authorizes the Office of the Secretary of State to conduct a background verification to confirm the assertions and information provided herein. 1. I am a U.S. citizen or an alien admitted for permanent residence. 2. I have been a resident of Illinois for at least 30 days. 3. I am age 18 or older. NOTARIAL OATH State of Illinois, County of____________________________________ 4. I have never been convicted of a felony. 5. I am able to read and write the English language. 6. I have never had a notary public commission revoked. AFFIX NOTARY SEAL HERE THIS BOND MUST BE WRITTEN BY A COMPANY QUALIFIED WITH THE ILLINOIS DEPARTMENT OF INSURANCE TO WRITE SURETY BONDS IN THE STATE OF ILLINOIS. The Office of the Secretary of State does not recommend any particular bonding or insurance company. Know all by these presents that we ________________________________________________________________________________as principal/applicant and ____________________________________________________________________ are held firmly bound unto the People of the State of Illinois, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators and assigns jointly and severally, firmly by these presents. THE CONDITION OF THE ABOVE OBLIGATION IS SUCH THAT, whereas, the above bound principal/applicant has applied for appointment by the Secretary of State of the State of Illinois as a Notary Public for a four-year term. x ______________________________________________________ x ______________________________________________________ BOND NUMBER Signature of Principal/Notary Public Applicant Now, if said principal/applicant shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective date of the principals's/applicant's commission to the expiration date of the same. Signature of Authorized Representative of Surety Company AFFIX CORPORATE SEAL HERE Printed by authority of the State of Illinois. March 2016 -- 1 -- I 171.8 American LegalNet, Inc. www.FormsWorkFlow.com