Form Ssn-514 - Application For Appointment & Reappointment For Notary State At Large March 2008
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1
2TREY GRAYSON
KENTUCKY SECRETARY OF STATE
APPLICATION FOR APPOINTMENT & REAPPOINTMENT FOR NOTARY STATE AT LARGE
PURSUANT to the provisions of KRS 423.010, the undersigned applies to the Secretary of State of the Commonwealth of Kentucky to be
State at Large
appointed to the Office of Notary Public for the
. 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)
4.
Home address of applicant: ______________________________________________________________________________________
(street)
____________________________________________________________________________________________________________
(city)
(state)
(zip)
county of residence or county
5.
If a KENTUCKY RESIDENT,
in which applicant’s principal place of employment is located:
(official signature below must be from same county listed on line 5)
.
___________________ County
, county
If a person is NOT A RESIDENT OF KENTUCKY, but is employed in Kentucky
in which the applicant’s principal place of
employment is located: _________________________ County.
6.
Application is being made for
new appointment or
reappointment. If a reappointment, present commission will expire:
Month ____ Day ____ Year ___. (If previously a notary public and commission has expired, please check new appointment).
Please do not send your application for reappointment earlier than four (4) weeks before your current commission is to expire).
7.
Applicant must meet following requirements: 1) eighteen (18) years of age; 2) if a Kentucky resident, a resident of the above-named
county or principally employed in the county from which he or she is making application and if not a resident of Kentucky and
employed in Kentucky, is principally employed in the above named county from which he or she is making application; 3) of good
moral character, i.e., not a convicted felon or if a convicted felon, civil rights have been restored by executive order; and 4) capable of
discharging the duties imposed upon the Office of Notary Public.
8.
Signature of applicant:___________________________________________________________________________________________
PLEASE NOTE
BEFORE
YOU MUST COMPLETE THE CERTIFICATE OF APPROVAL BY OFFICIAL
MAILING TO 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, 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.
SIGNATURE OF OFFICIAL:_________________________________________________________________________________________
PLEASE PRINT OR TYPE NAME:____________________________________________________________________________________
OFFICIAL TITLE (INCLUDE COUNTY):______________________________________________________________________________
**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.
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