Renewal Application For Notary Commission Form - Business Services Division: Notary

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NEBRASKA SECRETARY OF STATE

Business Services Division: Notary

1445 K St., 1301 State Capitol Bldg.

P. O. Box 95104 * Lincoln, NE 68509

RENEWAL APPLICATION FOR NOTARY COMMISSION

Please type or print legibly in black ink. Applications will be rejected for incomplete responses.

This application is only accepted within the 30 days immediately preceding your current commission expiration date.

APPLICANT INFORMATION

Last Name

First

M.I.

Date

Home Address

Street

Apartment/Unit #

Address

PO Box (if any)

City

State

Zip

Home Phone

E-mail Address (optional)

Business Address (Required for non-resident applicant, optional for resident applicant)

Company Name

Street

Address

City

State

Zip

Work Phone

Extension

Non-resident applicants must also submit an Evidence of Employment in Nebraska form.

NOTARY PUBLIC QUALIFICATIONS IN THE STATE OF NEBRASKA

Since last commissioned:

3. Has your name changed?

YES

1. Have you been convicted of a felony?

YES

3a. If yes, please give previous name:

4. If you are bilingual, would you allow

2. Have you been convicted of a crime

your name to be placed on a list of

YES

involving fraud or dishonesty?

bilingual Notaries?

2a. If yes, please detail the conviction, the state and the date of

4a. List languages in which you are fluent:

the crime:

(attach additional pages if needed)

5. List date current commission expires:

NOTARIAL OATH

Your signature below w ill be used to verify your signature on other docum ents. You m ust sign consistently.

State of ______________________________ County of _____________________________

I, ____________________________________________, do solemnly (swear), (affirm) under penalty of perjury, that the answers to all questions on this application

are true and complete to the best of my knowledge; and, I do solemnly (swear) (affirm) that upon appointment, I will support the Constitution and laws of the United

States and the State of Nebraska, and I will faithfully discharge the duties of Notary Public in and for the State of Nebraska according to the best of my ability.

X_____________________________________________________

Applicant’s Signature

Subscribed and (sworn) (affirmed) before me: this _______ day of _______________, 20 ______.

(Month)

(Year)

________________________________________________________________

Signature of Notary Public

Revised 08/01/2013

Affix Official Notary Seal^