Jesse White • Illinois Secretary of State Resident Notary Public Application Index Department, 111 E. Monroe Springfield, IL 62756 Telephone: 217-782-7017 Type or Print Clearly $10 Filing Fee Commission Name Style: (Printed name must be identical to signature in Oath.) Last Name: Male First Name: Middle or Initial: Residence Address: (Street/route, City, ZIP) Mailing Address: (P.O. Box, Suite, Apt.) Female County: Home phone: Business phone: Name of Employer: Address of Employment: (Street, City, ZIP) Date of Birth: mm/dd/yyyy / / Applying for: New Commission Current Expiration Date: Renewal of Current Commission Commission #: Has your name, address or county changed since your last commission? Yes No If yes, please give previous name: _____________________________________________________________________________ and/or address: ____________________________________________________________________________________________ NOTARIAL OATH State of Illinois 1. 2. 3. 4. 5. 6. County of _____________________________ I am a U.S. citizen or an alien admitted for permanent residence. I have been a resident of Illinois for at least 30 days. I am at least age 18 years or older. I have never been convicted of a felony. I am able to read and write the English language. I have never had a notary public commission revoked. 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 this State; 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. Signature of Applicant: _____________________________________________ Notary Public Signature: ____________________________________________ Witnessed and Affirmed this day _________ of _________________________ 20_______. AFFIX SEAL HERE Printed by authority of the State of Illinois. January 2005 – 15M – I-171.3 American LegalNet, Inc. www.USCourtForms.com ILLINOIS NOTARY PUBLIC BOND 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 Name of Applicant (type or print) ____________________________________________________________________________________________________________ Name and Address of Surety Company ____________________________________________________________________________________________________________ are held and 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. 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 principal’s/applicant’s commission to the expiration date of the same. x ______________________________________________ Signature of Principal/Notary Public Applicant Bond Number must be placed in this box. x ______________________________________________ Signature of Authorized Representative of Surety Company Corporate Seal must be placed in this box. THIS BOND MUST BE WRITTEN BY A COMPANY QUALIFIED WITH THE ILLINOIS DEPARTMENT OF INSURANCE TO WRITE SURETY BONDS IN THE STATE OF ILLINOIS. Notary Public applications and commissions are public records and are available to any interested person for examination and copying. NOTE: The Notary Public commission is not valid until you have registered your signature with your County Clerk of residence. The Notary Public should verify the accuracy of the information of the certificate before obtaining a Notary Public stamp. DO NOT WRITE BELOW THIS LINE Printed by authority of the State of Illinois. January 2005 – 15M – I-171.3 American LegalNet, Inc. www.USCourtForms.com