Fee: $80.00 (4-year term) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Office of the Secretary of State Corporations Division Notary Public Section 148 W. River Street Providence, Rhode Island 02904-2615 APPLICATION FOR APPOINTMENT AS NOTARY PUBLIC OR JUSTICE OF THE PEACE To be executed and returned to the Secretary of State, together with the fee of $80.00. Applicant must be either a registered voter in the State of Rhode Island or an attorney who is a member of the Rhode Island Bar. All applicants, new or renewals, must complete section 1, section 2A or 2B as applicable, and section 3. NEW RENEWAL Date: ___________________ To the Governor of the State of Rhode Island: 1. All applicants must complete this section. Sign the application as you would to vote. I, (print or type name) _________________________________________________, the undersigned, residing at (number, street, city, state, zip),________________________________ __________________________________________________________ do hereby request appointment to the office of NOTARY PUBLIC (or JUSTICE OF THE PEACE) and enclose herewith $80.00, the required fee for such commission. ________________________________________________ SIGNATURE OF APPLICANT 2. You must be a registered voter in the State of Rhode Island or an attorney who is a member of the Rhode Island Bar. All applicants, new or renewals, must have section A completed unless they are members of the Rhode Island Bar. Members of the Bar must complete section B. A. Take or send the application to the Board of Canvassers in your city or town. The following is to be signed by a member or staff of the Board of Canvassers, certifying that you are a registered voter. I HEREBY CERTIFY that the above applicant was, on the above date, a duly qualified elector of the City/Town of _______________________________________. ________________________________________________ SIGNATURE OF CANVASSERS MEMBER OR STAFF OF THE BOARD OF B. A member of the Rhode Island Bar is not required to have the application certified by the Board of Canvassers. However, a copy of your current Rhode Island Bar card or a certified copy of your Certificate of Admission to the Rhode Island Bar must be filed with this application. I, the above applicant, am a member of the Rhode Island Bar. __________________ ________________________________________________ BAR NUMBER SIGNATURE OF APPLICANT IF A MEMBER OF RI BAR PLEASE CONTINUE ON BACK American LegalNet, Inc. www.USCourtForms.com 3. All applicants must complete this section and have it notarized. CERTIFICATE OF ENGAGEMENT ON COMMISSION Official Signature of the Officer Engaged: ________________________________________________ Signature as it will appear on commission _________________________________________________________ Write the words NOTARY PUBLIC or JUSTICE OF THE PEACE ________________________ COUNTY, In the City/Town of ___________________________ and County and State aforesaid, on the ______ day of _________________, 20___, personally came_________________________________________, and made oath/affirmation to support the Constitution of the United States and the Constitution and Laws of Rhode Island, and faithfully and impartially discharge the duties of the office of NOTARY PUBLIC or JUSTICE OF THE PEACE for said State according to the best of his/her abilities. ________________________________________________ NOTARY PUBLIC or JUSTICE OF THE PEACE Commission expiration date: ______________________ Produced identification Personally known by me Pursuant to state law, the filing fee is $80.00. Checks must be made payable to the Secretary of State. Return application with filing fee to Office of the Secretary of State, Corporations Division, Notary Public Section, 148 W. River Street, Providence, Rhode Island 02904-2615. The Notary Section can be reached at 222-1487, from 8:30 am to 4:30 pm, Monday through Friday. You will receive your Notary Commission in the mail in approximately three (3) weeks. Your term will expire four (4) years from the date of commission. A renewal form will be mailed to you at the address listed, so please contact this office if you change your address. NOTE: In the State of Rhode Island, Justices of the Peace MAY NOT perform marriage ceremonies. LOCAL BOARDS OF CANVASSERS Barrington Town Hall, 283 County Rd. Bristol Town Hall, 10 Court St. Burrillville Town Hall, 105 Main St. Harrisville Central Falls City Hall, 580 Broad St. Charlestown Town Hall, 4540 S. County Trl. Coventry Town Hall, 1670 Flat River Rd. Cranston City Hall, 869 Park Ave. Cumberland Town Hall, 45 Broad St. East Greenwich Town Hall, 125 Main St. East Providence City Hall, 145 Taunton Ave. Exeter Town Hall, 675 Ten Rod Rd. Foster Town Hall, 181 Howard Hill Rd. Glocester Town Hall, 1145 Putnam Pike Hopkinton Town Hall, 1 Town House Rd. Jamestown Town Hall, 93 Narragansett Ave. Johnston Town Hall, 1385 Hartford Ave. Lincoln Town Hall, 100 Old River Rd. Little Compton Town Hall, 40 Commons Middletown Town Hall, 350 East Main Rd. Narragansett Town Hall, 25 Fifth Ave. Form No. NF-1 Revised: 12/05 247-1900 253-7000 568-4300 727-7450 364-1200 822-9150 461-1000 728-2400 886-8603 435-7502 294-2287 392-9200 568-6206 377-7777 423-9804 553-8856 333-1140 635-4400 849-5540 789-1044 Newport City Hall, 43 Broadway New Shoreham Town Hall, Old Town Rd., PO Box 220 North Kingstown Town Hall, 80 Boston Neck Rd. North Providence Town Hall, 2000 Smith St. North Smithfield Town Hall, 575 Smithfield Rd. Pawtucket City Hall, 137 Roosevelt Ave. Portsmouth Town Hall, 2200 East Main Rd. Providence City Hall, 25 Dorrance St. Richmond Town Hall, 5 Richmond Townhouse Rd Scituate Town Hall, 195 Danielson Pike, North Scituate Smithfield Town Hall, 64 Farnum Pike, Esmond South Kingston Town Hall, 180 High St., Wakefield Tiverton Town Hall, 343 Highland Rd. Warren Town Hall, 514 Main St. Warwick City Hall, 3275 Post Rd. West Greenwich Town Hall, 280 Victory Hwy. West Warwick Town Hall, 1170 Main St. Westerly Town Hall, 45 Broad St. Woonsocket City Hall, 169 Main St. 846-9600 466-3200 294-3331 232-0900 767-2200 722-1637 683-3157 421-0495 539-2497 647-7466 233-1000 789-9331 625-6704 245-7340 738-2000 392-3800 822-9201 348-2500 762-0027 FOR OFFICIAL USE Reviewed by: Check #: American LegalNet, Inc. www.USCourtForms.com