Form 4 STATE OF VERMONT Application of Notary Public and Official Oath/Affirmation County, ss Employment Address (NON-VT RESIDENTS ONLY) Name and Mailing Address (Please Print) Ex Officio I, (Position) Town or City of Residence Date of Birth do solemnly swear (declare and affirm) that I will faithfully execute the office of NOTARY PUBLIC for the State of Vermont, and will therein do equal right and justice to all persons to the best of my judgment and abilities according to law. SO HELP ME GOD. (Under the pains and penalties of perjury). I also solemnly swear (declare and affirm) that I will support the Constitution of the State of Vermont, and of the United States. SO HELP ME GOD. (Under the pains and penalties of perjury). Signature And at the said in said County, on this personally appeared day of , 20 and took the oath/affirmation of office prescribed by the Constitution of Vermont. Before me, Notary Public or Justice of the Peace Appointment of Notary Public THIS IS TO CERTIFY THAT the person whose name appears in the above mailing box, was, on the day of appointed by the Judges of the Superior Court, , 20 County, a NOTARY PUBLIC for the term ending on February 10, 20 . An ex officio notary public shall cease to be a notary public upon vacating the office on which their status as a notary public depends or at the end of the above term, whichever occurs first. Judges of the Superior Court { County Clerk's Office. The foregoing appointment and oaths/affirmations filed in this office this day of , 20 . Clerk/Deputy Clerk INSTRUCTIONS: 1) Print or type the following portion of the form a) name and mailing address b) residence c) date of birth. 2) Take the oath before a duly commissioned Notary Public or Justice of the Peace and sign your legal name. 3) Return this completed form with $20.00 to the county clerk in the county in which you reside. Rev 12/06 SML American LegalNet, Inc. www.FormsWorkflow.com