Notary Public Application
Jesse White — Illinois Secretary of State
Enclose $10 fee payable to Secretary of State. Return completed form to: Secretary of State Index Department, 111 E. Monroe, Springfield, IL 62756.
Middle Name or Initial:
Business Address (P.O. Box not acceptable):
Name of Employer:
Driver’s License or State Identification
Card Number (attach a photocopy):
Renewal of Commission
Date of Birth:
Current Expiration Date: _________ Commission Number: ____________
County of Residence:
Current Home Address (P.O. Box not acceptable):
Has your name, address or county changed since your last commission?
If, yes, give previous name, address and/or county: _______________________________________________________________________________________
AFFIX NOTARY SEAL HERE
NOTARY PUBLIC BOND
THIS BOND MUST BE WRITTEN BY A COMPANY QUALIFIED WITH THE ILLINOIS DEPARTMENT OF INSURANCE TO WRITE SURETY BONDS IN THE
STATE OF ILLINOIS. The Office of the Secretary of State does not recommend any particular bonding or insurance company.
Know all by these presents that we ________________________________________________________________________________as principal/applicant and
____________________________________________________________________ are held firmly bound unto the People of the State of Illinois, in the penal
sum of FIVE THOUSAND DOLLARS ($5,000), for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators and
assigns jointly and severally, firmly by these presents.
THE CONDITION OF THE ABOVE OBLIGATION IS SUCH THAT, whereas, the above bound principal/applicant has applied for appointment by the Secretary of
State of the State of Illinois as a Notary Public for a four-year term.
Now, if said principal/applicant shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to law, then the
above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective date of the principals’s/applicant’s
commission to the expiration date of the same.
Signature of Principal/Notary Public Applicant
Signature of Authorized Representative of Surety Company
AFFIX CORPORATE SEAL HERE
Printed by authority of the State of Illinois. March 2016 — 1 — I 171.8