Form 2301 - Application For Appointment As A Texas Notary Public, Notary Public Errors & Omissions Insurance Policy Page 2

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Bond Number

STATEMENT OF OFFICER

(Pursuant to Art. XVI, Section l(b) Texas Constitution)

I, ____________________________________, do solemnly swear (or affirm) that I have not directly or indirectly paid, offered, promised to pay, contributed, or promised

(Applicant’ s Name)

to contribute any money or thing of value, or promised any public office or employment for the giving or withholding of a vote at the election at which I was elected or as a

reward to secure my appointment or confirmation, whichever the case may be, so help me God.

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING STATEMENT AND THAT THE FACTS STATED THEREIN

ARE TRUE.

_____________________________

X________________________________________________

Date

Affiant’ s Signature

========================================================================================================================

Take the Official Bond form below to any insurance agency or bonding company for completion, unless it is preprinted with the name and address of an insurance

agency/surety company. If it is so preprinted, return it to the agency specified on the bond for completion. DO NOT ALTER THE BOND IN ANY MANNER. Only a

bond written on a company licensed in Texas to issue fidelity and surety bonds will be accepted. A premium will be collected by the insurance/surety company from which you

purchase the surety bond. The Texas Department of Insurance does not have a standard premium rate for this bond limit; thus, you must check with the insurance/surety company

for the approved premium rate.

OFFICIAL NOTARY PUBLIC BOND FOR THE STATE OF TEXAS

STATE OF TEXAS

COUNTY OF ____________________________

KNOW ALL PERSONS BY THESE PRESENTS: THAT WE, ___________________________________________________________________AS PRINCIPAL

(Applicant’ s Name)

AND___________________________________________________A CORPORATION DULY LICENSED TO DO BUSINESS IN THE STATE OF TEXAS, AS SURETY,

ARE HELD AND FIRMLY BOUND UNTO THE GOVERNOR OF THE STATE OF TEXAS AND TO HIS/HER SUCCESSORS IN OFFICE, IN THE SUM OF TEN THOUSAND

($10,000) FOR THE PAYMENT OF WHICH, WELL AND TRULY TO BE MADE WE BIND OURSELVES, OUR HEIRS, EXECUTORS AND ADMINISTRATORS JOINTLY

AND SEVERALLY BY THESE PRESENTS.

THE CONDITION OF THIS BOND IS SUCH THAT THE ABOVE NAMED PRINCIPAL HAS BEEN APPOINTED A NOTARY PUBLIC FOR THE STATE OF TEXAS SHALL

FAITHFULLY PERFORM THE DUTIES OF SAID OFFICE OF NOTARY PUBLIC, THEN THIS SHALL BECOME NULL AND VOID, OTHERWISE IT SHALL REMAIN IN

FULL FORCE AND EFFECT.

WITNESS OUR HANDS ON THIS ____________________DAY OF ___________________, 20_________.

__________________________________________________

INSURANCE OR BONDING COMPANY

BY___________________________________________________________

SIGNATURE OF SURETY OFFICER OR ATTORNEY IN FACT

______________________________________________________________

AGENCY NAME

______________________________________________________________

x____________________________________________

AGENCY ADDRESS

CITY

STATE

ZIP CODE

SIGNATURE OF PRINCIPAL (APPLICANT)

========================================================================================================================

INSTRUCTIONS

Complete both sides of this form using black ink or a typewriter.

THIS FORM MUST BE ONE PAGE, FRONT AND BACK (8 1/2 x 11).

RENEWALS: Same procedure and fee as required for obtaining original commission. A Notary Public may be reappointed upon submission of a new application

not earlier than ninety (90) days prior to the expiration of the Notary Public’s term. A Notary Public who is not reappointed on or before the expiration date of the

term the Notary Public is serving will be appointed for a new term expiring four years from the date of qualification.

COSTS TO BE A TEXAS NOTARY PUBLIC: Secretary of State fees $21.00; the applicable premium payable to the insurance/surety company from which you

purchase a $10,000 surety bond; and the costs of purchasing a personalized notary seal and record book (available from an office supply company).

Return the completed application, executed statement of officer and bond, and $21.00 payable to the Secretary of State to: Secretary of State of Texas, Notary Public

Unit, P. O. Box 13375, Austin, Texas 78711-3375 or 1019 Brazos, Austin, Texas 78701.

Form 2301