Notary Public Application - Illinois Secretary Of State

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Notary Public Application
Jesse White — Illinois Secretary of State
Enclose $10 fee payable to Secretary of State. Return completed form to: Secretary of State Index Department, 111 E. Monroe, Springfield, IL 62756.
Last Name:
First Name:
Middle Name or Initial:
Business Address (P.O. Box not acceptable):
Street:
City:
State:
ZIP Code:
Name of Employer:
Driver’s License or State Identification
Card Number (attach a photocopy):
■ ■
■ ■
Business Phone:
Date of Birth:
Applying for:
New Commission
Renewal of Commission
Current Expiration Date: _________ Commission Number: ____________
Mailing Address:
County of Residence:
Current Home Address (P.O. Box not acceptable):
Street:
City:
State:
ZIP Code:
■ ■
■ ■
Do you want your home address to be displayed to the public?
Yes
No
Home Phone:
■ ■
■ ■
Has your name, address or county changed since your last commission?
Yes
No
If, yes, give previous name, address and/or county: _______________________________________________________________________________________
AFFIX NOTARY SEAL HERE
NOTARY PUBLIC BOND
THIS BOND MUST BE WRITTEN BY A COMPANY QUALIFIED WITH THE ILLINOIS DEPARTMENT OF INSURANCE TO WRITE SURETY BONDS IN THE
STATE OF ILLINOIS. 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
____________________________________________________________________ are held 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-tear 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 principals’s/applicant’s
commission to the expiration date of the same.
x
x
______________________________________________________
______________________________________________________
Signature of Principal/Notary Public Applicant
Signature of Authorized Representative of Surety Company
BOND NUMBER
AFFIX CORPORATE SEAL HERE
♻ Printed on recycled paper. Printed by authority of the State of Illinois. April 2010 — 1 — I 171.6

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