State of North Carolina Department of the Secretary of State Elaine F. Marshall, Secretary of State APP LICATION FOR INITIAL APPOINTMENT AS A NORTH CAROLINA NOTARY PUBLIC Read the instru ctions com pletely before filling out this application . Please print in black ink or type . ull Legal Name ( F ull name with no initials ) Gender: M F * * You may use one initial for the first or middle name , but not for both. Commission name shall be a part of your full legal name, but not a nickname or shortened version of your legal name. No single initials without a full first or middle name are permitted. This name is how you will be commissioned and must appear exactly as such on your sea l. 3. Mailing Address: City: State: Zip: Residence Address if Different: City: State: Zip: 4. Home/Cell Phone: Business Phone + Ext : 5 . Last 4 D igits SSN# : 6 . Are you a United States citizen ? Yes No If n o, see instructions on the following page . 7. Home Email Ad dress : Business Email A ddress: 8. Birth Date : 9. High School Diploma 10 . County of Residence : or equivalent? Yes No 1 1 . Occupation : OR Unemployed Retired Student Self - Employed Business / Employer: C ounty Where Employed: Business Mailing Address: ( Address, City, State, Zip) 1 2 . You are required to complete a notary public education course. Provide information about the course here: Number of Class Hours: N ame of community college or educational or ganization P rint or type name of instructor D ate completed I hereb y certify that the above named applicant has succes sfully completed the notary p ublic education course and therefore qualifies for your consideration for a notary p ublic commission . S ignature of instructor D ate 1 3 . Are you a licensed member of the 14. D o you speak, read and write the 1 5 . Do you have a current NC Notary Public Manual ? N.C. State Bar? Yes No English language? Yes No Yes No If y es: Year 1 6 . Have you ever been con victed by any c ourt of a felony or misdemeanor? Have yo u been charged with an offense f or which trial is still pending ? Yes No If yes to either question, see instructions on following page. 1 7 . Have you ever had a professional licens e or n otary commission denied, revoked, restricted or suspended? Have you ever had to resign a license or commission under unfavorable circumstances? Yes No If yes to either question, see instructions on fo llowing page. 1 8 . I, , solemnly swear or affirm under penalty of perj ury that the information in commission name , same as # 2 above) this application is true, complete and co rrect; that I understand the official du ties and responsibilities of a notary p ublic in this State, as described in the statutes; that I can speak, read and write in the English language; and that I will perform to the best of m y ability all notarial acts in accordance with the law. Signature of Applicant : ( This signature must be signed before a notary and match the name o n line 2 above. This signature must be used when performing ALL n otari al ac ts .) ********************************************************************************************************** ******************************** DO NOT NOTARIZE YOUR OWN SIGNATURE. 19. This certificate must be notarized by a commissioned notary other than you. State of North Carolina, County of Sworn to (or affirmed) and subscribed before me this day of , 20 , By . (Name of Applica nt) Signature of Notary Public: DO NOT NOTARIZE YOUR OWN SIGNATU RE My Commission Expires on: , 20 (Revised April 2018 ) (Official Seal or Stamp) American LegalNet, Inc. www.FormsWorkFlow.com FORM MUST BE COMPLETE, LEGIBLE AND CORRECT OR APPLICATION MAY BE REJECTED OR DENIED PLEASE PRINT IN BLACK INK OR TYPE ASSISTANCE: The Notary Public Section is available for assistance from 8:00am to 5:00pm, Monday through Friday, with the exception of State H olidays. You may contact us by phone at (919) 814 - 5400 , by e - mail at notary@sosnc.gov , or by fax at (919) 807 - 2210. Visit our web site at www.sosnc.gov FEE: Make check or money order payable to NC Secretary of State in the amount of $50.00 . Fees are non - refundable (see N.C. General Statute 247 10B - 13). PLEASE DO NOT SEND CASH . Notary Public Section office will process your application within 72 hours of receipt under n ormal circumstances . MAIL APPLICATION AND FEE TO: Notary Public Section Please allow two (2) weeks to receive your oath notification letter. Department of the Secretary of State PO Box 29626 Raleigh, NC 27626 - 0626 APPLICATION INSTRUCT IONS - ALL INFORMATION REQUESTED IS REQ U I RED BY N.C. G.S. 10B - 5, 10B - 6 & 10B - 7 1. Enter your full legal name. This name should match the name on your official identification. 2. Enter the name you wish to use for your notary p ublic commission. You may use one initi al for the first or middle name, but not for both. The commission name shall be a part of your n ame , but not a nickname or shortened version of your legal name. No si ngle initials without a full first or middle name are permitted. 3. Enter your complete mailing and residence address es. The mailing address can be a P. O. Box, however, if your residence address is different from your mailing address , enter your resid ence address in t he space allowed. The residence address must show a physical location with a street number and name. 4. Enter your home or cell phone with area code. Enter your business phone with area code including your extension , if applicable . 5. Enter th e last four digits of your Social Security number. 6. If you are not a U.S. citizen, attach a copy of an unexpired U.S. government - issued document that permits you to reside and work in the United States, such as a permanent resident card (Form I - 551), an employment authorization card/document or a visa. Please note: you must continue to prove your federal permission to reside a nd work in the U.S. if the document submit ted expires before your notary commission . 7. Enter your complete home and business e mail address clearly and legibly. This s hould be updated as needed by e mail to our office at notary@sosnc.gov . 8. Enter the month, day and year of your birth . 9. Indicate whether you have a high school diploma or the equivale nt by c heck ing the appropriate box. 10. Enter your county of residence. If you are a North Carolina resident, this is the county where you will be commissioned. 11. Enter your occupation (i.e., bank teller, paralegal, attorney, realtor, etc.) If you are unemploye d, retired, a student, or self - employed, he county of your principal employment. If you are not a North Carolina res ident but your principal employment is in North Carolina, you must send proof of employment statement from your employer on company letterhead to be commissioned in the county of your employment. 12. You must complete the required six - hour notary p u blic education course to be commissioned as a n otary in North Carolina. Enter the name of the community C ollege or educational organization where you took the course, the name of your instructor, and t he date that you completed the course. Initial appli cants must have your instructor sign and date your application. Initial applicants are required to pass a written examination approved by the Secretary with a score of 80% or better. 1 3 . If you are an attorney licensed to practice law in North Carolina , check yes. (N. C. Licensed attorneys, although exempt, are strongly encouraged to take the n otary course. Attorneys are required to possess the most current n otary manual .) 1 4 . Indicate whether you can speak, read and write in the English lan guage by checking the appropriate box. 15. N.C. Gen. Stat. 247 10B - 5 requires that you pu rchase and keep the most recent edition of the N.C. Notary Public Manual . The Notary Public Manual for North Carolina may be purchased from t he School of Governm ent, UNC Chapel Hill, through their website at www.sog.unc.edu . Please visit the School of Government's website, email sales@sog.unc.edu , or call ( 919 ) 966 - 4119 for information about the latest edition. 1 6 . question, send a certified copy of your criminal record background chec