Application For Appointment As Notary Public

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Form # A-1 (Rev. 11/12/09)
FOR OFFICE USE ONLY
Notary Public Unit
Trans. #___________________________
Office of the Secretary of the State
Acct. #____________________________
State of Connecticut
PO Box 150470
Date of Appt._______________________
Hartford, CT 06115-0470
APPLICATION FOR APPOINTMENT AS NOTARY PUBLIC
PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE COMPLETING APPLICATION
An applicant must be 18 years of age or older and a resident of, or have a principal place of business in, Connecticut.
The entire application must be filled out legibly in ink in your own handwriting. All of the questions must be answered
completely.
The Certificate of Character on page 2 must be filled out completely and signed by a public official or a reputable
business or professional person who must be unrelated to you and have personally known you for at least on year.
The Jurat on page 6 must be completed and sworn to before a notary public or other appropriate official.
Return completed application to the Office of the Secretary of the State, at the above address, with a check or money
order made payable to the “Secretary of the State” in the amount of $120.00 (non-refundable statutory appointment
fee for a 5 year term).
1. Print name in full___________________________________________________________________________________
first
middle
last
1a. Print exact name you will use as a notary public (This is your name as it will appear on your certificate and the way
you must sign when performing notarial acts).
Male
Female
______________________________________________________________________________________________
2. Present residence address_____________________________________________________________________________
no.
street
town
state
zip code
Mailing address, only if mail delivery is not available to residence address____________________________________
________________________________________________________________________________________________
List prior residence addresses for the last three years:
Street
City/Town
State
Zip Code
___________________________________________________________________________________________________
___________________________________________________________________________________________________
____________________________________________________________________________________________________
3. Give name and address of your principal place of business in Connecticut, or the concern with which you are
connected and in what capacity.
Business name:_____________________________________________________________________________________
Address:__________________________________________________________________________________________
___________________________________________Business Phone:_________________________________________
4. What is your occupation?____________________________________________________________________________
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