Fillable Notary Public Application Instructions (New York State)

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Notary Public Application Instructions (New York State)

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New York State
Department of State
Division of Licensing Services
Notary Public
P.O. BOX 22065
Albany, NY 12201-2065
Customer Service: (518) 474-4429
www.dos.ny.gov
Notary Public Application Instructions
Please read all instructions carefully, as incomplete
applications will be returned. Send these materials to the
address indicated on the reverse side of this application.
Notary Public commissions automatically expire four years from
the effective date. It is important that you notify this division of
any changes in your address so you will continue to receive
renewal notices and other notifications pertinent to your
commission.
Oath of Office Instructions
To qualify for appointment, an oath of office must be signed in the
presence of a commissioned Notary and submitted to the Department
of State with your completed application and $60 fee. An
identification card, stating the effective and expiration dates of your
four-year commission, will be mailed to you directly by the
Department of State.
Application Instructions
1. The name printed in which you wish to be commissioned must
conform exactly to the signature that will be used as a notary
public. Initials may be used, as in John A. Doe or J. Arthur
Doe, but NOT J. Doe or J.A. Doe.
2. The use of a P.O. Box as the only address is not acceptable. A
street address is required. County clerk employees should use
the county clerk address. Non-resident notaries must use the
street address of their New York State business. Please note:
Addresses are subject to disclosure under the Freedom of
Information Law (FOIL). If you do not want your home
address released, you must provide a business address.
3. Examination admission requirements: You must have taken and
passed the NYS Notary Public Examination. Examination results
are only valid for a period of two years. If you are an attorney
who is currently a member of the New York State Bar or a court
clerk of the Unified Court System, appointed to that position
after taking a Civil Service promotional examination in the court
clerk series of titles you are not required to have taken and passed
the examination. Attorneys and court clerks are not exempt from
the application fee.
PRIVACY NOTIFICATION
Do I need to provide my Social Security and federal ID numbers on
the application?
Yes, if you have a social security number or Federal ID number, you are
required to provide this number. If you do not have a social security
number or Federal ID number, please provide a written explanation.
The Department of State is required to collect the federal Social Security
and Employer Identification numbers of all licensees. The authority to
request and maintain such personal information is found in §5 of the Tax
Law and §3-503 of the General Obligations Law. Disclosure by you is
mandatory. The information is collected to enable the Department of
Taxation and Finance to identify individuals, businesses and others who
have been delinquent in filing tax returns or may have underestimated
their tax liabilities and to generally identify persons affected by the taxes
administered by the Commissioner of Taxation and Finance. It will be
used for tax administration purposes and any other purpose authorized by
the Tax Law and may also be used by child support enforcement agencies
or their authorized representatives of this or other states established
pursuant to the Title IV-D of the Social Security Act, to establish, modify
or enforce an order of support, but will not be available to the public. A
written explanation is required where no number is provided. This
information will be maintained in the Licensing Information System by
the Director of Administration and Management, at One Commerce
Plaza, 99 Washington Avenue, Albany, NY 12231-0001.
Return this original application (no photocopies)
along with:
A non-refundable $60 fee. You may pay by check or money order
made payable to the Department of State or charge any fee to
MasterCard or Visa, using a credit card authorization form. Do not
send cash. A $20 fee will be charged for any check returned by
your bank.
(Note: The $60 fee includes the $40 State fee and the $20 County
fee)
Note: This form may not be used to renew your license.
County Clerk Employees Only
You must include a notarized fee exemption statement in lieu of
the fee.
DOS-0033-f-a (Rev. 04/18) page 1 of 2
WOULD YOU LIKE TO REGISTER TO VOTE?
Please visit the NY State Board of Elections at www.elections.ny.gov/votingregister.html
or call 1-800-FOR-VOTE to request a NYS Voter Registration form.
To register online, please visit www.ny.gov/services/register-vote.
FOR OFFICE APPT UNIQUE
USE ONLY DATE: ID:
FOR OFFICE UNIQUE CASH FEE New York State
USE ONLY ID NUMBER $60
Department of State
Division of Licensing Services
Notary Public
P.O. BOX 22065
Albany, NY 12201-2065
Customer Service: (518) 474-4429
www.dos.ny.gov
NOTARY PUBLIC APPLICATION PLEASE TYPE OR PRINT & RETURN THIS ORIGINAL FORM
NAME IN WHICH YOU WISH TO BE COMMISSIONED (MUST CONFORM TO SIGNATURE)
L
A
ST N
A
ME FIRST N
A
ME MIDDLE
SOCIAL SECURITY NUMBER (see privacy notification) FEDERAL ID NUMBER (see privacy notification) DAYTIME PHONE NUMBER
NYS HOME ADDRESS: (if your legal residence is outside of NYS skip this section & complete the “NYS Business Name & Address” below
STREET ADDRESS:
CITY:
NY
ZIP CODE: COUNTY:
NYS BUSINESS NAME:
NYS BUSINESS STREET ADDRESS:
CITY:
NY
ZIP CODE: COUNTY:
1.
The date you passed the NYS Notary Public Examination (see exemptions on reverse side)
__________________
2.
Are you 18 years or older?
3.
Are you currently a member of the NYS Bar?
4.
Are you currently a Court Clerk of the Unified Court System, appointed to that position after taking a civil service
promotional examination in the court clerk series titles?
_________________________________________________
5.
Have you ever been convicted of a crime or offense (not a minor traffic violation) OR has any license, commission
or registration ever been denied, suspended or revoked in this state or elsewhere?
(If yes, you must include details/documentation)
6. Are there any criminal charges (misdemeanor or felony) pending against you in any court in this state or elsewhere?
(If yes, you must submit a
copy of the accusatory instrument indictment, criminal information or complaint)
YES NO
YE
S NO
YES NO
YES NO
YES NO
I subscribe and affirm, under the penalties of perjury, the statements in this application are true and correct.
Applicant Signature X
Date
OATH OF OFFICE
LAST NAME FIRST NAME MIDDLE
NYS HOME ADDRESS: (if your legal residence is outside of NYS skip this section & complete the “NYS Business Name & Address” below
STREET ADDRESS:
CITY: ZIP
CODE: COUNTY:
NY
NYS BUSINESS NAME:
NYS BUSINESS STREET ADDRESS:
CITY: ZIP
CODE: COUNTY:
NY
Oath of Office I do solemnly swear (or affirm) that I will support the Constitution of the United States and the Constitution of the
State of New York State New York, and that I will faithfully discharge the duties of the office of Notary Public for the State of New
County of York according to the best of my ability.
Applicant Signature X
Date
Sworn to before me on this day of
(County Clerk or Notary Public)
DOS-0033-f-a (Rev. 04/18)
Notary Public Stamp
page 2 of 2
Become an Organ and Tissue Donor
Organ donors save lives. If you would like to be an organ and tissue donor upon your death, you may enroll in the
NYS Donate Life Registry online at www.donatelife.ny.gov/register or complete the form below. Completed forms
should be sent to the NYS Donate Life Registry by email --- Registry@donatelife.ny.gov or, mail - NYS Donate Life
Registry, 185 Jordon Road, Troy, NY 12180.
Fields with an asterisk (*) are required for enrollment. Upon receipt of your completed enrollment form, you will be
sent an email or letter confirming your enrollment and providing you with information on how to limit your donation.
I understand that by opting out of enrolling in the NYS Donate Life Registry, or skipping this question, will not impact
or impair my ability to obtain services from the New York Department of State, Division of Licensing Services.
*Last name
*First name
Middle Initial Suffix
*Address
*Apt. Number *Zip Code
*City
*Birth date / / *Gender M
F
MM DD YYYY
Email address
DMV or IDNYC Number
By signing below, you certify that you are:
• 16 years of age or older;
• Consenting to donate your organs and tissues for
transplantation and/or research in the event of your death;
• Authorizing the New York Department of State, Division of
Licensing Services to transfer your name and identifying
information to the NYS Donate Life Registry for
enrollment;
and
• Authorizing the Registry to give access to this information
to federally regulated organ procurement organizations
and NYS-licensed tissue and eye banks and others
approved by the NYS Commissioner of Health in the event
of your death.
*Sign *Date
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Notary Public Application Instructions (New York State)

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Completed 17 August 2020

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