Kentucky Notary Public Handbook And Forms Page 3
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16C
K
OMMONWEALTH OF
ENTUCKY
A
L
G
, S
S
LISON
UNDERGAN
RIMES
ECRETARY OF
TATE
_________________________________________________________________________________________________________________________
Division of Corporations
Notary Public State at Large
Notary Commissions
Application for Appointment or Reappointment
PO Box 821
Frankfort, KY 40602
(Limited Liability Company or Limited Partnership)
(502) 564-3490
Pursuant to the provision of KRS 423.010, the undersigned applies to the Office of the Secretary of State to be appointed by the Governor of
Kentucky to the Office of Notary Public-State at Large. For this purpose the undersigned applicant makes the following statements:
1. Name of applicant:__________________________________ _________________________________________________________________
(Please print or type name as it is to appear on your commission certificate.)
2. Date of birth: ____________________________________________
3. Daytime phone number__________________________________
(month-day-year)
(Include area code)
4. Home address of applicant where notification will be mailed:___________________________________________________________________
______________________________________________________________________________________________________________________
5. County of Commission (County specified for 5a of 5b must match the county of the official signature below on the “Certificate of Approval”)
a.
Kentucky County of Residence:_____________________________________
or
Kentucky County where the applicant’s principal place of employment is located____________________
b.
6. Application is being made for:
new appointment
reappointment (
my commission expires on: Month ____ Day ____ Year _____) (Please do not send your
application for reappointment earlier than four (4) weeks before your current commission is to expire.)
7.
Check the box if you wish to have your mailing address published on the notary website.
CERTIFICATE OF APPROVAL
(Must be completed by a county official BEFORE mailing to the Secretary of State Notary Commissions)
The undersigned, an official authorized by statute to approve this application, states that the applicant herein is over eighteen (18) years of
age, if a Kentucky resident, is a resident of or principally employed in the above-named county, or if not a Kentucky resident, but is employed in
Kentucky, is principally employed in the above named county, is of good moral character (not a convicted felon), and is capable of discharging the
duties imposed by law upon the Office of Notary Public of the Commonwealth of Kentucky. NOW, THEREFORE, by virtue of the foregoing
statements I have made and the authority granted to me by statute, my approval to the foregoing application is hereby granted.
Name of Official:
_____________________________________________________________________________________________________________________
(Please Print or Type)
Signature of Official:_____________________________________________________________________________________________________
Official’s Title: _______________________________________________ Official’s Coun ty___________________________________________
(Please
)
(
Print or Type
Please Print or Type)
Please Note: The Certificate of Approval must be signed by one of the following officials: Circuit Judge, Circuit Clerk, County Judge/Executive, County
Clerk, Justice of the Peace (Magistrate) or Member of the General Assembly of the county of residence of the applicant or in the county in which the
applicant’s principal place of employment is located. (Official signature must match county listed on line 5.)
Email Address (to receive future notary reminders):_____________________________________________________________________________
ignature of Applicant: _____________________________________________________________________________
S
)
(01/12
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