NOTARY NO._______________________ APPLICATION AND DECLARATION FOR NOTARY PUBLIC GEORGIA, GWINNETT COUNTY To the Honorable Tom Lawler, Clerk of Superior Court of said County: I, the undersigned, do hereby submit my application to be a Notary Public under the provisions of the Official Code of Georgia, Sections, 45-17-5, 45-17-6, 45-17-7, as amended and show that: (1) I reside in Gwinnett County at the Address of:_______________________________________________ ____________________________________________________________________________________ (1) I am at least 18 years of age; and (2) I can read and write the English Language; and (3) I have an operating telephone number______________________ ;and (4) I “ (have) “ (have not) had a denial, revocation, suspension, restriction or resignation of a notary commission held by me, and that I “ (have) “ (have not) been convicted of a criminal act, including any plea of nolo contendere. (Not to include minor traffic violations.) (If you checked “have” to either of the above, provide complete details on the reverse side of the application and sign same.) I,____________________________________________, do solemnly swear or affirm under penalty of perjury that the personal information I have written in this application is true, complete and correct. X______________________________________________ APPLICANT STATE OF GEORGIA GWINNETT COUNTY On this______day of_______________________, 20____, before me appeared____________________ ________________________________________________, the person who signed the preceding declaration of applicant in my presence and who swore or affirmed that _____ (he/she) understood the document and freely declared it to be truthful. ________________________________________________ NOTARY PUBLIC Affix seal and expiration date. ENDORSEMENT 1. I,_____________________________________, being 18 years of age or older and a resident of Gwinnett County, believe the applicant for Notary Public commission, _________________________________ ________________________, who is not related to myself, to be a person of integrity, of good moral character and capable of performing notarial acts. DATE:____________ X______________________________________________ ________________________________________________ ________________________________________________ Endorser’s signature and home address American LegalNet, Inc. www.FormsWorkflow.com ENDORSEMENT 2. I,_____________________________________, being 18 years of age or older and a resident of Gwinnett County, believe the applicant for Notary Public commission, ___________________________ ________________________, who is not related to myself, to be a person of integrity, of good moral character and capable of performing notarial acts. DATE:____________ X______________________________________________ ________________________________________________ ________________________________________________ Endorser’s signature and home address APPOINTMENT (TO BE COMPLETED BY CLERK’S OFFICE) Having complied with all regulations required by law to become a Notary Public, and it appearing that said applicant is at least 18 years of age, of good moral character and integrity, and qualified to perform notarial acts, it is hereby ordered that said applicant be and is hereby appointed Notary Public, as prayed for, upon said applicant taking and subscribing the oath as prescribed by law. DATE OF APPOINTMENT:_____________________________ DATE TERM EXPIRES:________________________________ AGE:_____________ SEX:______________________________ PHONE:_________________ ______________________ Home Business OATH OF OFFICE I,_______________________________________________, do solemnly swear or affirm that I will well and truly perform the duties of a Notary Public to the best of my ability, and I further swear or affirm that I am not the holder of any public money belonging to the state and unaccounted for, so help me God. ________________________________________________ Sworn to and subscribed before me this_____day of_______________________, 20_____. _____________________________________________ DEPUTY CLERK Gwinnett County Superior Court REVISED 6-07 American LegalNet, Inc. www.FormsWorkflow.com