Have you ever been a notary public in this or any other state? ■■ Yes ■■ No
If yes, list the states: ______________________________________________________________________________________________________________
NOTARIAL OATH State of Illinois, County of____________________________________
I do solemnly affirm, under the penalty of perjury, that the answers to all statements on this application are true, complete and correct; that I have carefully read
the notary law of the State of Illinois; and that if appointed and commissioned as a notary public, I will perform faithfully, to the best of my ability, all notarial acts in
accordance with the law. Further, my signature below authorizes the Office of the Secretary of State to conduct a background verification to confirm the assertions
and information provided herein.
Printed Name as you
want commissioned ________________________________________________________________________
Signature of Applicant
as Printed Above __________________________________________________________________________
Notary Public Signature:_____________________________________________________________________
Witnessed and Affirmed this ____________ day of _______________________________, 20 _____________
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 one-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.
x ______________________________________________________ x ______________________________________________________
Signature of Principal/Notary Public Applicant Signature of Authorized Representative of Surety Company
BOND NUMBER AFFIX CORPORATE SEAL HERE
Non-resident 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.
Printed by authority of the State of Illinois. October 2018 — 1— I 172.4
1. I am a U.S. citizen or an alien admitted for permanent residence.
2. I have worked or maintained a business in Illinois for 30 days.
3. I am age 18 or older.
4. I have never been convicted of a felony.
5. I am able to read and write the English language.
6. I have never had a notary public commission revoked in the last 10 years.
Last Name: First Name: Middle Name or Initial:
Name of Business Employer: Driver’s License or State ID
Card Number (attach a photocopy):
Business Address:
Street: City: State: ZIP Code:
Business Telephone Number: Date of Birth: Applying for:
■■ New Commission ■■ Renewal of Commission
Current Expiration Date: _________ Commission Number: ____________
County of Business: Home Phone:
Home Address:
Street: City: State: ZIP Code:
Has your name, address or county changed since your last commission?
■■ Yes ■■ No
If yes, give previous name, address and/or county: ______________________________________________________________________________________
