Notary Public - Special Commission Application For Appointment

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OMMONWEALTH OF

ENTUCKY

ECRETARY OF

TATE

LISON

UNDERGAN

RIMES

_________________________________________________________________________________________________________________________

Division of Corporations

Notary Public - Special Commission

Notary Commissions

Application for Appointment

PO Box 821

Frankfort, KY 40602

(502) 564-3490

(Limited Liability Company or Limited Partnership)

Pursuant to the provision of KRS 423.110(6), the undersigned applies to the Office of the Secretary of State to be appointed by the Governor of Kentucky

to the Office of Notary Public-Special Commission. For this purpose the undersigned applicant makes the following statements:

1. Name of applicant: ________________________________________________________________________________________________________

(Please print or type name as it is to appear on your commission certificate.)

2. Date of birth: ____________________________________________

3. Daytime phone number: ___________________________________

(month-day-year)

(Include area code)

4. Home address of applicant where notification will be mailed: _______________________________________________________________________

________________________________________________________________________________________________________________________

5. County of Commission (County specified for 5a of 5b must match the county of the official signature below on the Certificate of Approval)

a. Kentucky County of Residence:_______________________________________________________________________________________

b. Kentucky County from which the application is being made, if non-resident:___________________________________________________

Check the box if you wish to have your mailing address published on the notary website.

CERTIFICATE OF APPROVAL

(Must be completed by a county official BEFORE mailing to the Secretary of State Notary Commissions)

The undersigned, an official authorized by statute to approve this application, states that the applicant herein is over eighteen (18) years of age,

if a Kentucky resident, is a resident of or principally employed in the above-named county, or if not a Kentucky resident, but is employed in Kentucky,

is principally employed in the above named county, is of good moral character (not a convicted felon), and is capable of discharging the duties imposed

by law upon the Office of Notary Public of the Commonwealth of Kentucky. NOW, THEREFORE, by virtue of the foregoing statements I have made

and the authority granted to me by statute, my approval to the foregoing application is hereby granted.

Name of Official: ____________________________________________________________________________________________________________

Please Print or Type

Signature of Official:__________________________________________________________________________________________________________

Official’s Title: ____________________________________________________ Official’s County___________________________________________

Please Print or Type

Please Note: The Certificate of Approval must be signed by one of the following officials: Circuit Judge, Circuit Clerk, County Judge/Executive, County Clerk,

Justice of the Peace (Magistrate) or Member of the General Assembly of the county of residence of the applicant or in the county in which the applicant’s

principal place of employment is located. (Official signature must match county listed on line 5.)

Email Address (to receive future notary reminders):_________________________________________________________________________________

Signature of Applicant

: __________________________________________________________________________________________________

(Signature of Applicant must match the name as it appears on line 1)

(01/12)