PERSONAL INFORMATION
Full Name:
(Last) (First) (Middle)
Home Address:
(Street) (City) (State) (County) (Zip)
Place of Employment: Unemployed Retired
Business Address:
(Street) (City) (State) (County) (Zip)
Mail to: Home Business Other Address:
(Street/P.O. Box) (City) (State) (Zip)
Sex: Male Race: Asian
E-mail Address: F
emale Black or African American
(or write “NONE”) Native American or Alaska Native
White
Home Phone: Other: ________________________
(or write “NONE”)
Business Phone: Extension:
(or write “NONE”)
Florida Driver License (or other State of Florida Issued ID): Date of Birth: __________/__________/__________
(Month/Day/Year)
Social Security Number: ______-_____-_______
The disclosure of a Florida notary public applicant’s social security number is expressly required by Fla. Stat. §117.01(2) and is imperative for processing notary public
commission applications. Please be advised that social security numbers are only used for processing the notary public commission application and are exempt from
disclosure pursuant to Fla. Stat. §119.071(5)(a)5.
1. Are you a legal resident of Florida? Yes No (If No, you are not eligible to apply for a Florida notary public commission. Legal residency must be
maintained throughout the appointment.)
2. Are you a United States citizen? Yes No (If No, you must submit a recorded Declaration of Domicile. Obtain this document from your county
courthouse.)
3. Are you now or have you ever been commissioned a Notary Public in the State of Florida? Yes No (If No, you, must complete a 3 hour Notary
education course and submit a signed certificate of completion. Fla. Stat. §668.50 (11)(b).)
If Yes: __________/__________/__________
(Commission expiration date) (Commission number) (Name for which your commission was issued)
4. Have you held any professional licenses or commissions (other than Notary Public) in Florida during the past 10 years? Yes No
If Yes, please list:
Have any been revoked? Yes No (If Yes, you must submit a written statement about the nature of the action and a copy of the final order from the
regulating agency.)
5. Have you been disciplined by a regulatory agency, including the Florida Bar, and including disciplinary action that is confidential? Yes No
(If Yes, you must submit a written statement about the nature of the action and any supporting documentation, such as a copy of the final order from the regulating
agency.)
6. Have you been convicted of a felony or have you had an adjudication of guilt withheld for a felony offense? Yes No (If Yes, you must submit
a written statement of the nature of the offense(s), a copy of the court judgment and sentencing order. If convicted, you must submit a certificate of Restoration of
Civil Rights.)
7. Are you currently on probation? Yes No
AFFIDAVIT OF CHARACTER
STATE OF COUNTY
am unrelated to and have knownI,
(Print or Type Name of Affiant) (Name of Applicant)
for one year or more; and to the best of my knowledge and observation know him or her to be of good character.
My address is
(Street) (City) (State) (County) (Zip)
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING AFFIDAVIT AND THAT THE FACTS STATED IN IT
ARE TRUE.
Home Phone: (_____) Work Phone: (_____) X
(or write “NONE”) (or write “NONE”) (Signature of Affiant)
1
NOTARY PUBLIC COMMISSION APPLICATION
Florida Department of State
Notary Commissions and Certifications Section (850) 245-6975
