Notary Public Application Form And Renewal Instructions Page 2
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Application/Renewal for Notary Public
__________________
S
S
C
TATE OF
OUTH
AROLINA
Date received
O
S
S
FFICE OF THE
ECRETARY OF
TATE
T
H
M
H
HE
ONORABLE
ARK
AMMOND
New _______ Renewal_______
To: Governor of the State of South Carolina
I respectfully petition to be appointed Notary Public for this State, and for your information, I herewith submit the following:
PLEASE PRINT
Name ______________________________________________________________________________________________________
Mailing Address __________________________________ City ________________________ Zip Code ______________________
Home Street Address ____________________________________City ________________________ Zip Code _________________
*You must be a registered voter at the home address provided on this application.
County _______________________ Last 4 Digits of your Social Security # ___ ___ ___ ___ Sex ____ Date of Birth ___/____/___
Voter Registration # __________________________
(Voter Registration Number may be obtained from your County Voter Registration and Election Office or the State Election Commission.)
(____)______________________
Telephone #
E-mail__________________________________________________________
[ ]
By checking this box, I hereby certify that I can read and write the English language.
OATH OF NOTARY PUBLIC
I do solemnly swear (or affirm) that I am duly qualified, according to the Constitution of South Carolina, to exercise the duties of the
office to which I have been appointed and that I will, to the best of my ability, discharge the duties thereof and preserve, protect and
defend the Constitution of this State, and of the United States. So help me God.
Sworn to and subscribed before me
___________________________________________
This _________ day of _________________, 20___________
Signature of applicant
Print
__________________________________________________
Name _______________________ Date:
Notary Public of South Carolina
*Please sign and print your name exactly as you
__________________________________________________
will sign when you notarize documents. The commission
Printed Name
will be issued in this name.
My Commission Expires _____________________________
Mail application to delegation for required signatures (addresses and telephone numbers are on the front of the application).
This section must be completed by your Legislative Delegation. Please choose one of the three options.
We, the _______________________________________Delegation, recommend the appointment of the above named applicant.
(
County)
1)
2)
________________________________________________
____________________________________________________
Signature of the Delegation Chairman OR Secretary
Signature of Senator / Senate District #__________________
_____________________________________________________
Signature of House Member / House District # ______________
3)
Signed by at least half of the present Legislative Delegates from applicant’s county of residence:
________________________________________
_________________________________________
________________________________________
_________________________________________
________________________________________
_________________________________________
________________________________________________
_________________________________________________
Form Revised by South Carolina Secretary of State, April 2015
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