Notary Public Commission Application Form

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NOTARY PUBLIC COMMISSION APPLICATION
Florida Department of State
Notary Commissions (850) 245-6975
This application and the information it contains, except social security numbers, are public record and will be available on the Division's website.
Full Name:
(Last)
(First)
(Middle)
Home Address:
(Street)
(City)
(State)
(County)
(Zip)
Place of Employment:
Unemployed
Retired
Business Address:
(Street)
(City)
(State)
(County)
(Zip)
Mail to:
Home
Business
Other Address:
(Street/PO Box)
(City)
(State)
(Zip)
Sex:
E-mail Address:
M
F Race:
(or write “NONE”)
Home Phone: (
)
Business Phone: (
)
Extension
(or write “NONE”)
(or write “NONE”)
Florida Driver’s License (or other State of Florida Issued ID):
Date of Birth: ____/____/____
(Month/Day/Year)
1.
Are you a legal resident of Florida? Yes
No
(If No, you are not eligible to apply for a notary commission. Legal residency must be maintained throughout the appointment.)
2.
Are you a United States citizen?
Yes
No
(If No, you must submit a recorded Declaration of Domicile. Obtain this document from your County Courthouse.)
3.
Are you now or have you ever been commissioned a Notary Public in the State of Florida? Yes No
If No, you, must complete a 3 hour Notary education course
and submit a signed certificate of completion. (Ch. 668.50 (11) F.S.)
If Yes:
/
/
(Commission expiration date)
(Commission number)
(Name in which your commission was issued)
4.
Have you held any professional licenses or commissions (other than Notary Public) in Florida during the past 10 years? Yes No
(If yes, please list.)
Have any been revoked? Yes
No
(If Yes, you must submit a written
statement about the nature of the action and any supporting documentation, such as a copy of the Final Order from the regulating agency.)
5.
Have you been disciplined by a regulatory agency, including the Florida Bar, and including disciplinary action that is confidential? Yes No
(If Yes, you must submit a written statement about the nature of the action and any supporting documentation, such as a copy of the Final Order from the regulating agency.)
6.
Have you been convicted of a felony, had adjudication of guilt withheld, or are you on probation? Yes
No
(If Yes, you must submit a written statement of
the nature of the offense(s), a copy of the court judgment and sentencing order. If convicted, you must submit a certificate of Restoration of Civil Rights.)
AFFIDAVIT OF CHARACTER
STATE OF
COUNTY
I,
am unrelated to and have known
(Print or Type Name of Affiant)
(Name of Applicant)
for one year or more; and to the best of my knowledge and observation know (him)(her) to be of good character.
My address is
(Street)
(City)
(State)
(County)
(Zip)
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING AFFIDAVIT AND THAT THE FACTS STATED IN IT
ARE TRUE.
Home Phone: (_____)
X
(or write “NONE”)
(Signature of Affiant)
Work Phone: (_____)
(or write “NONE”)
OATH OF OFFICE
STATE OF FLORIDA
COUNTY
I DO solemnly (swear) (affirm) that I will support, protect and defend the Constitution and Government of the United States and of the State of Florida;
that I am duly qualified to hold office under the Constitution of the State of Florida; that I have read Chapter 117, Florida Statutes, and any amendments
thereto, and know the duties, responsibilities, limitations, and powers of a notary public; and that I will honestly, diligently, and faithfully discharge the
duties of Notary Public, State of Florida on which I am now about to enter, (so help me God).
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING APPLICATION AND OATH AND THAT THE FACTS
STATED THEREIN ARE TRUE. I accept the office of Notary Public, State of Florida.
X
(Signature of Applicant- This is the name in which your commission and notary seal will be issued)
/
/
(Print or Type Name- Must match signature)
(Date)
Social Security Number: _____/_____/_____
NPC01 (6/10)

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