Commonwealth of Virginia Secretary of the Commonwealth Application for Appointment as Notary Public _______________________________________________________________________ Instructions: 1. PRINT LEGIBLY OR TYPE ALL ANSWERS. APPLICATION MUST BE COMPLETED FRONT AND BACK. All questions must be answered or the application will be returned. 2. Make check or money order for $45.00 payable to the Treasurer of Virginia. Each application must be accompanied by a check. Checks must note the name(s) of each applicant on the face of the check. 3. Return this application completed in full with your check or money order to: Notary Clerk, Office of the Secretary of the Commonwealth, P.O. Box 1795, Richmond, VA 23218-1795. Part 1: (Please circle one: Male, Female) (Please circle one: New Applicant, Renewal) 1. Name: _________________________________________________________ If renewing, is this a name change? Yes  No  As your commission will read (Must be the same as the name on your state issued ID) 2. ____________________________________________3. Date of Birth: _______/_________/________________ *Notary Registration Number* mm dd yyyy 4. Home Address: __________________________________________________________________________________________ Number & Street or Post Office Box City/Town State Zip Code If renewing, is this home address a new address? Yes  No  5. Please Check One (If Applicable): Unemployed ________ Retired ________ Student _________ Self-Employed ________ 6. Present Employer (If Applicable): ___________________________________________________________________________ 7. Business Address: ________________________________________________________________________________________ Number & Street or Post Office Box City/Town State Zip Code If renewing, is this business address a new address? Yes  No 8. Preferred Mailing Address (Please Check One): Home_______ or Business_________ 9. (______) _________________________10. (_____) _____________________ 11. (______)______________________________ Home Telephone Number Work Telephone Number Cell Phone Number 12. __________________________________ Circuit Court in which you wish to receive your commission. 13. Please Check: Yes No Are you at least 18 years old? Do you read and write English? Have you ever been convicted of a felony? Failure to answer this correctly will subject you to criminal penalties and automatic revocation of your commission. Provide Date(s), Court(s), and Offense(s) for each felony conviction, If yes: _______________________ _______________________ ____________________________ Date(s) of Conviction(s) Court(s) Offense(s) Have your Civil Rights been restored by a Governor following felony conviction(s)? If yes, please provide documentation of your Restoration of Rights with your application. Are you currently serving as a Notary Public in Virginia? The Certificate evidencing your appointment as Notary Public contains the following words: “… in the year of our Lord...” If you would like to have these words omitted from your certificate, check this box. American LegalNet, Inc. www.FormsWorkFlow.com Part 2: Please put your initials next to each statement indicating that you understand the information provided. _____ A Virginia Notary Public must be familiar with and understand everything contained in “The Handbook for Virginia Notaries Public.” The handbook is located on the following website: http://www.commonwealth.virginia.gov/OfficialDocuments/Notary/notary.cfm _____ A notary must always be completely satisfied with the identity of the person whose signature is being notarized. A notary is not obligated to notarize a person’s signature without being sure that the person is who he or she claims to be. Always check identification and be satisfied that the identification is valid. Never accept the word of a third party as being sufficient for identification to justify notarizing a person’s signature. _____A notary is not required to charge a fee for his or her services, but if a fee is a charged; it cannot be for more than $5.00 for each document notarized. _____A notary is not authorized to perform marriages or certify birth, marriage or death certificates nor any act that constitutes the practice of law. _____A notary must provide the following items on each document notarized: 1. The name of the county or independent city in which the document is signed. 2. The date it is signed. 3. Notary’s statement 4. The notary’s signature 5. The date the notary’s commission expires 6. The notary’s registration number 7. A photographically reproducible seal or stamp _____A notary must not notarize a signature that is on a different page than the notary statement without the proper certificate wording on the same page as the signature. _____A notary must notify the Secretary of the Commonwealth’s Office with any changes to the information provided on this application. _____If there are any changes to the notary law, the information will be available by July 1 of every year on our website http://www.commonwealth.virginia.gov/OfficialDocuments/Notary/notary.cfm or by calling the Secretary of the Commonwealth’ Office. Part 3: I the undersigned Applicant do hereby swear (or affirm) that the information supplied herein is true and complete, to the best of my knowledge and belief. Signature of Applicant ________________________________________________________________________________________ (This signature must match the name used in signing ALL notarized documents) City/County of ____________________________________ State/Commonwealth of ____________________________ Acknowledged and sworn to before me this ___________ day of __________________, 200_____ __________________________________________________________ Signature of Virginia Notary or other Virginia officer authorized to administer oaths _________________________________ Expiration Date ______________________________________________________ Notary Registration Number (or official title if not a notary) NOTE: By law, you must claim your commission within 60 days after it is issued. If you fail to do so you must submit a new application and a new fee to become a Notary. If you have not received a notice of your commission within four weeks call the Secretary of the Commonwealth’s Office at (804) 692-2536 or by emailing to socmail@governor.virginia.gov Sometimes notices are lost in the mail. Failure to receive a notice will not permit you to receive a commission after the 60-day period has expired. Revised July 2009 American LegalNet, Inc. www.FormsWorkFlow.com