Application For Appointment As A Notary Public In The State Of Indiana Form - Secretary Of State, State Of Indiana
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2Do Not Write In This Box - For Office Use Only
Commission # _________________________________ Expiration Date of New Commission ___________________________________________
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA
Complete and Return to:
Notary Department, Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317-232-6542
To: THE GOVERNOR OF INDIANA
I respectfully request that I be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond,
oath of office, and fee of FIVE DOLLARS ($5), payable to the Secretary of State, in the form of a check or money order. (Do not send currency in
the mail.) (IC 33-16-2-1)
PRINT OR TYPE
1.
NAME __________________________________________________________________________________________________________
Your legal signature in which commission will be issued - see instruction #3
2.
HOME ADDRESS __________________________________________________________________________________________________
Number and street
__________________________________________________________________________________________________________________
City
State
ZIP code
3.
COUNTY OF RESIDENCE _____________________________________________________________________________________
Business or Employer's Name _____________________________________________________________________________________
4.
5.
Business or Employer's Address ___________________________________________________________________________________
Street
City
State
ZIP code
(
)
(
)
6.
HOME PHONE _______________________________________ OFFICE PHONE ________________________________________
Area Code
Number
Area Code
Number
7.
If you have a current valid notary commission, show your expiration date:
__________________________________, 19 ____
8.
If you are now a notary public and your name or county has changed since your last application, please give both old and new information.
OLD: ___________________________________________________________________________________________________________
NEW: __________________________________________________________________________________________________________
9.
NOTARIAL OATH
)
STATE OF INDIANA
SS:
)
COUNTY OF _______________________________
County in which oath is administered
I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of Indiana; that I am duly
qualified to hold office under the Constitution and laws of the State; that I am 18 years of age or over; that I am of good moral character and integrity;
that I am a resident of Indiana; that my answers to questions on this application are true and complete to the best of my knowledge; that I have
carefully read all of the instructions which came with this application, and that I will faithfully and impartially discharge the duties of NOTARY
PUBLIC if so commissioned by the Governor, according to the best of my skill and ability, so help me God (or under the pains and penalties of
perjury).
Signature of applicant
Subscribed and sworn or affirmed to before me, this _____ day of ________________________________________
Place Officer's Seal Here
A.D. 19 _____. IN TESTIMONY WHEREOF, I, _____________________________________________________
Printed or typed name of officer
______________________________________________, a ________________________________________ for the
Signature of a notary public or other officer authorized to administer oaths
Office
C o u n t y o f _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , S t a t e o f I n d i a n a .
Officer's county of residence
M y c om m i s s i on ex p i re s : _ _ __ _ __ _ __ _ __ _ _ __ _ __ _ __ _ __ _ _ __ _ __ _ __ _ __ _ _ __ _ __ _ __
NOTE: The Bond Form, starting with #10 on the back of this application, must be completed before mailing to the Secretary of State.
The applicant must sign again in #10.
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