Form # A-1 (Rev. 4/25/2014) FOR OFFICE USE ONLY Trans. #___________________________ Acct. #____________________________ Date of Appt._______________________ Notary Public Unit Office of the Secretary of the State State of Connecticut PO Box 150470 Hartford, CT 06115-0470 PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE COMPLETING APPLICATION · · · · APPLICATION FOR APPOINTMENT AS NOTARY PUBLIC An applicant must be 18 years of age or older and a resident of, or have a principal place of business in, Connecticut. The entire application must be filled out legibly in ink in your own handwriting. All of the questions must be answered completely. The Certificate of Character on page 2 must be filled out completely and signed by a public official or a reputable business or professional person who must be unrelated to you and have personally known you for at least one year. The Jurat on page 6 must be completed and sworn to before a notary public or other appropriate official. Return completed application to the Office of the Secretary of the State, at the above address, with a check or money order made payable to the "Secretary of the State" in the amount of $120.00 (non-refundable statutory appointment fee for a 5 year term). 1. PRINT name in full_________________________________________________________________________________ first middle last 1a. PRINT exact name you will use as a notary public (This is your name as it will appear on your certificate and the way you must sign when performing notarial acts). Male Female ______________________________________________________________________________________________ first middle last 2. Present residence address_____________________________________________________________________________ no. street town state zip code Mailing address, only if mail delivery is not available to residence address____________________________________ ________________________________________________________________________________________________ 3. Phone Number __________________________________ 4. Email (optional)___________________________________ 5. Give name and address of your principal place of business in Connecticut. Business name:_____________________________________________________________________________________ Address:__________________________________________________________________________________________ ___________________________________________Business Phone:_________________________________________ 6. What is your occupation?____________________________________________________________________________ 7. Date of Birth________________________________8. Town & State of Birth___________________________________ 9. Highest degree awarded and school attended______________________________________________________________ ___________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 10. For what purpose do you expect most frequently to use a notary public appointment? __________________________________________________________________________________________________ __________________________________________________________________________________________________ ___________________________________________________________________________________________________ 11. Have you ever been convicted of a felony or misdemeanor? If yes, please provide date, charge, town, court and terms of sentence. Do not list parking tickets. Yes. No._________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 12. Have you ever been a notary public in Connecticut? If yes, indicate under what name, date of appointment and account number and address._______________________________________________________________________________ ____________________________________________________________________________________________________ 13. Have you at any time been refused a notarial commission, or had a notarial commission revoked. If yes, please provide the state, reason and date. Yes. No.________________________________________________________________________________________ CERTIFICATE OF CHARACTER I,_______________________________________________of__________________________________________________, (town & state) occupation__________________________________________________________________hereby certify that I have known_________________________________, the above named applicant, for the past_________________year(s), and know him/her to be a person of good moral character, and that the applicant is, in my opinion, a suitable person to receive the appointment of Notary Public. Date_____________________________Signature___________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com NOTARY PUBLIC EXAMINATION This examination is divided into four sections and must be completed in the applicant's own handwriting. Each question of each section must be answered correctly before an applicant will be appointed a Notary Public. The answers to all questions will be found in the Notary Public Manual. The staff of the Office of the Secretary of the State will not assist you in the completion of this examination because it is a test of your basic understanding of the duties and responsibilities of the Notary Public in the State of Connecticut. Section 1 ­ Place an X in the box corresponding to either true or false for each of the following statements: True False 1. A Connecticut notary may perform notarial acts anywhere in the United States. 2. A notary's embossing seal is not required by Connecticut state law. 3. A notary may not advise persons regarding questions of law. 4. If a notary's employer pays the fee of that notary's appointment, the notary's stamp and seal are the property of the employer. 5. In taking an acknowledgement, it is sufficient for a notary to require only one form of identification from an individual if that form of identification contains a photo. 6. A notary may use a rubber stamp as a substitute for his signature. 7. A resident notary must record his/her oath of office with the town clerk in the town in which he/she resides. 8. A notary should not perform notarial acts in Connecticut with documents that are in the cust