Form Ds/de 76 - Notary Public Commission Application Form With Memorandum printable pdf download

NOTARY PUBLIC COMMISSION APPLICATION

Florida Department of State

Notary Commissions and Certifications Section (850) 245-6975

PERSONAL INFORMATION

Full Name:

(Last)

(First)

(Middle)

Home Address:

(Street)

(City)

(State)

(County)

(Zip)

 Unemployed

 Retired

Place of Employment:

Business Address:

(Street)

(City)

(State)

(County)

(Zip)

Mail to:  Home  Business

 Other Address:

(Street/P.O. Box)

(City)

(State)

(Zip)

 Male

 Asian

Sex:

Race:

 Female

 Black or African American

E-mail Address:

 Native American or Alaska Native

(or write “NONE”)

 White

 Other: ________________________

Home Phone:

(or write “NONE”)

Business Phone:

Extension:

(or write “NONE”)

Florida Driver License (or other State of Florida Issued ID):

Date of Birth:

__________/__________/__________

(Month/Day/Year)

Social Security Number: ______-_____-_______

The disclosure of a Florida notary public applicant’s social security number is expressly required by Fla. Stat. §117.01(2) and is imperative for processing notary public

commission applications. Please be advised that social security numbers are only used for processing the notary public commission application and are exempt from

disclosure pursuant to Fla. Stat. §119.071(5)(a)5.

Are you a legal resident of Florida?  Yes  No

(If No, you are not eligible to apply for a Florida notary public commission. Legal residency must be

maintained throughout the appointment.)

Are you a United States citizen?  Yes  No

(If No, you must submit a recorded Declaration of Domicile. Obtain this document from your county

courthouse.)

Are you now or have you ever been commissioned a Notary Public in the State of Florida?  Yes  No

(If No, you, must complete a 3 hour Notary

education course and submit a signed certificate of completion. Fla. Stat. §668.50 (11)(b).)

If Yes:

__________/__________/__________

(Commission expiration date)

(Commission number)

(Name for which your commission was issued)

Have you held any professional licenses or commissions (other than Notary Public) in Florida during the past 10 years?  Yes  No

If Yes, please list:

Have any been revoked?  Yes  No

(If Yes, you must submit a written statement about the nature of the action and a copy of the final order from the

regulating agency.)

Have you been disciplined by a regulatory agency, including the Florida Bar, and including disciplinary action that is confidential?  Yes  No

(If Yes, you must submit a written statement about the nature of the action and any supporting documentation, such as a copy of the final order from the regulating

agency.)

Have you been convicted of a felony or have you had an adjudication of guilt withheld for a felony offense?  Yes  No

(If Yes, you must submit

a written statement of the nature of the offense(s), a copy of the court judgment and sentencing order. If convicted, you must submit a certificate of Restoration of

Civil Rights.)

Are you currently on probation?  Yes  No

AFFIDAVIT OF CHARACTER

STATE OF

COUNTY

am unrelated to and have known

(Print or Type Name of Affiant)

(Name of Applicant)

for one year or more; and to the best of my knowledge and observation know him or her to be of good character.

My address is

(Street)

(City)