Form Np-659-007 - Application For Appointment Or Reappointment As A Notary Public

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BUSINESS AND PROFESSIONS DIVISION
NOTARY PUBLIC SECTION
P.O. BOX 9027
OLYMPIA, WA 98507-9027
(360) 664-1550
FOR VALIDATION ONLY
APPLICATION FOR APPOINTMENT OR REAPPOINTMENT AS A
NOTARY PUBLIC
FEE: $20.00
Make remittance payable to: WASHINGTON STATE TREASURER
Proof of $10,000 surety bond must be provided.
PLEASE TYPE OR PRINT CLEARLY
001-000-256-0001
APPLICANT INFORMATION
Original Appointment
Reappointment
Applicant Name ___________________________________________________________________________________
FIRST NAME OR INITIAL
MIDDLE NAME OR INITIAL
LAST NAME
Address _________________________________________________________________________________________
PO BOX/STREET
City
State
Zip Code
County
__________________________
________________
_________________
_____________________________
(
)
Telephone number____________________
WA Resident
Non-resident, State_____________________
DURING NORMAL BUSINESS HOURS
Date of Birth ________________
Sex
M
F
/
/
Social Security Number
MO.
DAY
YR.
PER RCW 26.23.150, THE SOCIAL SECURITY NUMBER IS REQUIRED TO BE ON THE LETTER.
Name on any previous Washington notary appointment, if different from above:
ENDORSER SIGNATURES
I, the undersigned endorser, being a person eligible to vote in the state of Washington, and of the age of 18 or more, believe
the applicant for a notary public appointment, who is not related to me, to be a person of integrity and good moral character
and capable of performing notarial acts.
1. ___________________________________
___________________________________
ENDORSER'S SIGNATURE
ADDRESS, CITY, STATE, ZIP
DATE OF SIGNING
2. ___________________________________
___________________________________
ENDORSER'S SIGNATURE
ADDRESS, CITY, STATE, ZIP
DATE OF SIGNING
3. ___________________________________
___________________________________
ENDORSER'S SIGNATURE
ADDRESS, CITY, STATE, ZIP
DATE OF SIGNING
APPLICANT PERSONAL DATA
1. Have you been convicted of a crime, misdemeanor or felony in this state, any other state, by the federal government,
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!
or any other jurisdiction within the past ten years?
Yes
No
2. Is there a criminal complaint, accusation, or information presently pending against you or are you currently under
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!
indictment in this state, any other state, by the federal government, or any other jurisdiction?
Yes
No
3. Has any professional or occupational license, certification, or permit held by you, been fined, suspended, revoked,
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!
refused or denied in this state, any other state, by the federal government or any other jurisdiction?
Yes
No
4. Have you ever had a civil court order, verdict, or judgment entered against you in any court of competent jurisdiction
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!
in this state, any other state, by the federal government, or any other jurisdiction?
Yes
No
Please explain on the next page or attach a letter of explanation for any affirmative answers to the above
questions, including charge(s), date of conviction, civil judgement or order, county jurisdiction, state, and
disposition of charge(s).
The Department of Licensing has a policy of providing equal access to its services. If
you need special accommodation, please call (360) 753-3836 or TTY (360) 586-2788.
NP-659-007 NOTARY PUBLIC APP. (R/4/00)FM/W Page 2 of 3

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