Fillable Commonwealth of Massachusetts Notary Public Application

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Commonwealth of Massachusetts Notary Public Application

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The Commonwealth of Massachusetts Notary Public Application form is 4 pages long and contains:

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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INSTRUCTIONS
FOR THE NOTARY PUBLIC APPLICATION
Please read each question and answer carefully. Willfully making a false statement on this application is
punishable by up to twenty years in state prison pursuant to General Laws Chapter 268, Sections 1, 1A.
This application is valid for out-of-state applicants.
INSTRUCTIONS FOR ANSWERING QUESTION 1:
Please type or clearly print your given first name plus family name (surname) with whatever
middle initial(s), or middle name(s), if any, as bestowed with legal recognition. The fact that
you have one legal name provides a lawful designation and way of distinguishing you from
other individuals. Your surname can be changed at time of marriage, and either the given
or surname may be changed by order of court. Be mindful of how you sign your name. You
may wish to sign documents as a notary using only an initial or initials in place of the middle
name or names.
HOW YOU WILL SIGN DOCUMENTS AS A NOTARY IS
HOW YOUR NAME SHOULD APPEAR ON LINE 1
Please staple together the 4 pages of the application, and staple an up-to-date resume
Done at the end of the application.
If you have a business card please staple it to the upper left corner of the first page
Done of the application.
Please mail the entire completed application with all pages stapled together, to:
Notary Public Office
Room 184, State House
Boston, MA 02133
We will process your application promptly. Because of constitutional time parameters this process may
take as many as 18 days between the day on which you mail your application and the day when you
receive a notice of approval.
Date of mailing: _________
Date 18 days after date of mailing: _________
It will be on or about this future date when you will be notified by mail.
When your application is favorably considered, you will be notified by the Secretary of the
Commonwealth who will include with the notification of your appointment the directions for being sworn
in. At the same time you will be provided with instructions as to the manner and method for paying the
$60 commission fee to the Secretary of the Commonwealth. Please do not send a fee with this
application.
Do not send this page with your application
Do not send any payment with this application
To His Excellency the Governor
I hereby petition for appointment to the office of
NOTARY PUBLIC
Every application must be accompanied by an up-to-date resume that is stapled together with all of the pages of the
application.
Please type or print clearly
1. Applicant’s full name (please read instructions regarding this question): □Male □ Female
__________________________________________________
1.a Please list all other names by which you have previously been known, including but not
limited to any maiden name:
____________________________________________________________________________
2. Have you ever held a commission as a Notary Public in Massachusetts?
Yes □ No □ (if you answered yes, please answer the following three questions)
2.a When did or does your term expire?___________________________________________
2.b Have there been any complaints made about your commission? Yes □ No □
2.c If you have changed your name since your last appointment, please print your former name:
______________________________________________
3. Current residence:____________________________________________________________________
Street address (post office box not acceptable)
_____________________________________________________________________________________
City/Town, State Zip code County Length of time at this address
4. Current business address: ______________________________________________________________
Street address
_____________________________________________________________________________________
City/Town, State Zip Code County
5.
Daytime phone number : ___________________ Evening phone number: ____________________
6. Date of birth: ___/___/____ Place of birth: ________________________________________________
Town or City State Country
7. Have you ever been convicted of a crime? Yes □ No □
If you answered “yes” please attach an explanation on a separate page including the crime of conviction,
the date of conviction and the sentence imposed.
8. Have you ever had a professional license suspended or revoked? Yes □ No □
If you answered “yes” please attach an explanation on a separate page.
9. Have you ever been dismissed from a position due to actual or alleged misconduct or resigned from a
position in order to avoid dismissal?
Yes □ No □ If you answered “yes” please attach an explanation on a separate page.
10. Are there any other issues that, in the interest of full disclosure, should be considered in connection
with your application, qualifications, or suitability for appointment as a notary public?
Yes □ No □ If you answered “yes” please attach an explanation on a separate page.
Page 1 rev 3/7
11. Current occupation: _________________________________________________________________
12. Name of current employer_____________________________________________________________
13. Name of current supervisor:___________________________________________________________
14. Length of residence in Massachusetts:___________________________________________________
15. Previous residences for the past ten years:______________________________________________
Street address (post office box not acceptable)
_____________________________________________________________________________________
City or Town Zip Code County Length of time at this address
_____________________________________________________________________________________
Street address (post office box not acceptable)
_____________________________________________________________________________________
City or Town Zip Code County Length of time at this address
_____________________________________________________________________________________
Street address (post office box not acceptable)
_____________________________________________________________________________________
City or Town Zip Code County Length of time at this address
16. Names and locations of schools or universities that you have attended since age 18:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
17. Email address: _____________________________________________________________________
18. Please explain the reasons you are seeking a commission as a notary public:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Page 2 rev 3/7
TO BE COMPLETED BY THE APPLICANT:
I, __________________________________, do hereby state under the pains and penalties of perjury:
_____(initial here
) All of the information in this application and on my attached resume is accurate.
_____(initial here
) I acknowledge that any false statement in this application or on my attached resume will be
cause for revocation of the commission and may be prosecuted as a separate criminal offense.
_____(initial here) I understand that a notary public is empowered to perform the following notarial acts: (i)
acknowledgments; (ii) oaths and affirmations; (iii) jurats; (iv) signature witnessings; (v) copy certifications; (vi)
issuing summonses for witnesses pursuant to section 1 of chapter 233; (vii) issuing subpoenas; and (viii) witnessing
the opening of a bank safe, vault or box pursuant to section 32 of chapter 167.
_____(initial her
e) I understand that a notary public may witness signatures on documents for use in Massachusetts
and in other states. However, a notary public may only witness a signature so long as he or she is physically
present in Massachusetts at the time of the notarization.
_____(initial her
e) I understand that a notary public is a public servant performing a public duty. If a notary public
is performing notarizations at a place of business, the notary public may not decline to notarize a document for a
person who is not conducting business with the notary public’s employer. For example, if the notary public works
at a bank, the notary public may not decline to notarize a document solely because a person is not a client of that
bank.
_____(initial her
e) I understand that a notary public may only charge the amount set forth in statute for performing
a notarization. It is the notary public's responsibility to know the proper amount to charge. In no case may a notary
public charge more than the statutory amount.
_____(initial here) I understand that a notary public must ensure that the person signing a document to be notarized
is who he or she says he or she is. This means that the person signing the document or acknowledging his or her
earlier signature must appear in person before the notary public and the notary public must ask for and receive
satisfactory evidence of identity from the person who signed the document before performing the notarization.
_____(initial her
e) I have read Chapter 222 of the General Laws, as amended by Chapter 289 of the Acts of 2016,
and agree to comply with all of its terms. I understand that failure to do so may subject me to revocation
proceedings as well as civil and criminal penalties. I take personal responsibility for my actions as a notary public.
Applicant's signature
Please be mindful how you sign your name. See instructions page.
TO BE COMPLETED BY A CURRENT MASSACHUSETTS NOTARY PUBLIC:
COMMONWEALTH OF MASSACHUSETTS )
_______________, S.S. )
On this ____ day of ___________, 20__, before me, the undersigned notary public, personally appeared
________________________, who proved to me through satisfactory evidence of identification, which
was/were _______________________, to be the person who signed the preceding document in my
presence and who swore or affirmed to me that the contents of the document are truthful and
accurate to the best of his or her knowledge and belief.
__________________________________ (official signature and seal of notary)
My commission expires ________________________
Page 3 rev 3/7
Applicant’s full name (print clearly)________________________________________________________
TO BE COMPLETED BY FOUR REFERENCES
We, the undersigned, certify under the pains and penalties of perjury that the applicant:
(1) is known to each of us; (2) is of high standing and character; and (3) is in every way fitted for the
position of Notary Public. We are willing that this certification may be made public, if necessary.
(1) Attorney*
____________________________ ___________________________
Signature Date
____________________________ ___________________________ ____________________
Print Name Massachusetts Residence Relationship to applicant
(City or Town)
(2)
____________________________ ___________________________
Signature Date
____________________________ ___________________________ ____________________
Print Name Massachusetts Residence Relationship to applicant
(City or Town)
(3)
____________________________ ___________________________
Signature Date
____________________________ ____________________________ ____________________
Print Name Massachusetts Residence Relationship to applicant
(City or Town)
(4)
____________________________ ___________________________
Signature Date
____________________________ ____________________________ _____________________
Print Name Massachusetts Residence Relationship to applicant
(City or Town)
*This certificate must be signed by four persons, of whom one must be a member of the bar in good
standing.
Please staple all four pages of the application, along with an up-to-date copy of your resume, to:
Notary Public Office
Room 184, State House
Boston, MA 02133
Do not send any payment with this application.
Page 4 rev 3/7
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Commonwealth of Massachusetts Notary Public Application

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Completed 22 May 2020

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