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Have any been revoked?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
OATH OF OFFICE
STATE OF FLORIDA ________________________ COUNTY
I do solemnly swear (or affirm) that I will support, protect, and defend the Constitution and Government of the United States and of the State of Florida;
that I am duly qualified to hold office under the Constitution of the state; that I have read Chapter 117, Florida Statutes, and any amendments thereto, and
know the duties, responsibilities, limitations, and powers of a notary public; and that I will well and faithfully perform the duties of Notary Public, State of
Florida, on which I am now about to enter. So help me God.*
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING APPLICATION AND OATH, AND THAT THE FACTS
STATED THEREIN ARE TRUE. I accept the Office of Notary Public, State of Florida.
/ /X
(Official Signature of Applicant) (Date)
*Note: If you affirm, you may omit the words
“So help me God.” Fla. Stat. §92.52.
(Print or Type Name Name for which your commission will be issued)
MEMORANDUM
AS A GENERAL MATTER, APPLICATIONS FOR ALL POSITIONS WITHIN STATE GOVERNMENT ARE PUBLIC RECORDS, WHICH MAY
BE VIEWED BY ANYONE UPON REQUEST. HOWEVER, THERE ARE SOME EXEMPTIONS FROM THE PUBLIC RECORDS LAW FOR
IDENTIFYING INFORMATION RELATING TO SOCIAL SECURITY NUMBERS, PAST AND PRESENT LAW ENFORCEMENT OFFICERS
AND THEIR FAMILIES, VICTIMS OF CERTAIN CRIMES, ETC. IF YOU BELIEVE AN EXEMPTION FROM THE PUBLIC RECORDS LAW
APPLIES TO YOUR FLORIDA NOTARY PUBLIC COMMISSION APPLICATION SUBMISSION, PLEASE CHECK THE FOLLOWING BOX:
Yes, I assert that identifying information provided in this application (other than my social security number, which I am aware is automatically
exempt from public disclosure, pursuant to
Fla. Stat. §119.071(5)(a)5) should be excluded from inspection under Public Records Law.
If Yes, please indicate what section of Florida Statutes provides this exemption in your particular situation:
IF YOU NEED ADDITIONAL GUIDANCE AS TO THE APPLICABILITY OF ANY PUBLIC RECORDS LAW EXEMPTION TO YOUR
SITUATION, PLEASE CONTACT THE OFFICE OF THE ATTORNEY GENERAL:
Office of the Attorney General
The Capitol, PL-01
Tallahassee, FL 32399
(850) 245-0158
###
2
STATE OF FLORIDA
BOND OF NOTARY PUBLIC
FOR OFFICE USE ONLY
Approved by Department of State:
(Name of Applicant)
Signed and sealed this day of , .
Secretary of State
Notary Commissions
STATE OF FLORIDA
KNOW ALL MEN BY THESE PRESENTS, That we,
as Principal, and
as Surety Company, give bond payable to any individual who may be harmed as a result of a breach of duty by said applicant
acting in his/her official capacity as Notary Public, in the amount of
Dollars ( )
as assurance for the due discharge of the duties of his/her office of Notary Public and we do bind ourselves, and each of our heirs,
executors and administrators, jointly and severally.
Applicant was, on the date of issuance of commission, bonded as a Notary Public in and for the State of Florida, to hold office for
the term of four years in accordance with the Constitution and Laws of this State.
Now, therefore, if said applicant shall faithfully discharge the duties of the office of Notary Public, as prescribed by law, then this
obligation shall be void.
By
(Telephone Number)(Imprint Name of Surety Company)
(Affix Surety Seal)
Section 817.234(1)(b), F.S. "Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in
the third degree."
DS/DE 76 (3/04)
Bond No.
(Signature of Applicant)
X
(Name of Surety Company)
(Address of Surety Company)
(Signature of Florida Licensed Agent)
(Florida Licensed Agent Number)
(Printed name of Florida Licensed Agent)
(Name of Bonding Agency or Company)
X
RLI Insurance Company (309) 692-1000
Seven Thousand Five Hundred and No/100's $ 7,500.00
Roy C. Die Attorney in Fact
RLI Insurance Company
P.O. Box 3967
Peoria, IL 61612
Vermost & Associates, LLC
A273323
Darren J. Vermost
This bond shall be for Seven Thousand Five Hundred and No/100's Dollars ($ 7,500.00).
After execution by surety company, the bond must be submitted to the Department of State for approval and filing
before issuance of the notary public commission.
N0900207-50,30
1200 Belcher Road South, Suite 1, Largo, FL 33771
Platinum Package $174.99
$7500 Notary Bond, 4 year
State Application Fee
FREE Online Notary Course
FREE Shipping
Platinum Notary Self-Inking Seal
$5000 Errors & Omissions Insurance
Hand-Held Seal Embosser
FL Notary Public Primer
Notary Public Recording Journal Book
Wedding Package $169.99
$7500 Notary Bond, 4 year
State Application Fee
FREE Online Notary Course
FREE Shipping
Platinum Notary Self-Inking Seal
$5000 Errors & Omissions Insurance
Hand-Held Seal Embosser
Marriage Kit
Basic Package $121.99
$7500 Notary Bond, 4 year
State Application Fee
FREE Online Notary Course
FREE Shipping
Basic Notary Self-Inking Seal
$5000 Errors & Omissions Insurance
ALL Prices
INCLUDE
Florida State
& Local Sales
Taxes*
Notary Public Package & Supplies Pricing
Product Description Price*
Notary Public Package Options
Platinum Package $174.99
Wedding Package $169.99
Basic Package $121.99
Additional / Replacement Supplies
Basic Self-Inking Seal $21.99
Platinum Self-Inking Seal $31.99
Desk Seal Embosser $44.99
Hand-Held Seal Embosser $31.99
Marriage Kit $36.95
Florida Notary Public Primer $26.95
Notary Public Recording Journal Book $21.95
Name Change with New Basic Stamp $46.99
Address Change or Certificate Replacement No Charge
Additional Errors & Omissions Insurance (4 Year Protection)
Upgrade to $10,000 of E&O Protection $15.00
Upgrade to $15,000 of E&O Protection $40.00
Upgrade to $30,000 of E&O Protection $60.00
*Prices Include Florida State & Local Sales Tax when applicable.
Special Note Regarding Errors & Omissions (E&O) Insurance:
ALL of our packages include $5,000 worth of E&O Insurance protection.
We believe so strongly in your protection that we make it part of all of our packages.
BUT, can you aord to hire an attorney to defend yourself if you make an unintentional
mistake as a Notary Public?
Don’t leave yourself exposed; consider purchasing additional protection!
Mail Application & Order Form to: Vermost Insurance Agency • 1200 Belcher Rd S • Ste 1 • Largo, FL 33771
727-748-2886 • 800-828-2226 • www.FLNotaryPublic.com
BEST
Value
BEST Value
Basic Seal
$21.99
Platinum Seal
$31.99
– Self-Inking Seals
Marriage Kit
Florida law allows ALL Notary Publics to perform marriage
ceremonies. Our Wedding Kit includes everything you need
to perform the ceremony—except the bride and groom. Kit
includes:
• 10 Certificates Suitable for Framing
• 10 Gold Seals
• Sample Scripts
• Marriage Handbook
Marriage Kit is included in the Wedding Package.
$36.95
Florida Notary
Public Recording
Journal
Ecient and confidential
method of recording
and protecting notarial
information. Room for 81 entries with sample jurats and
simple easy to follow instructions.
This is highly recommended for all Notary Publics. This item
is included in the Platinum Package.
$21.95
Florida Notary Public
Primer
This manual explains the procedures,
laws, and certificate wording you
need to perform all of your Notary
Public functions with confidence.
Great quick reference material!
This item is included in the Platinum
Package.
$26.95
Mail Application & Order Form to: Vermost Insurance Agency • 1200 Belcher Rd S • Ste 1 • Largo, FL 33771
727-748-2886 • 800-828-2226 • www.FLNotaryPublic.com
Hand-Held Seal Embosser
Lightweight, portable, hand-held embosser
is used to leave a raised impression on
your valuable papers. Includes a carrying
case.
This embosser is NOT an ocial seal, but
is useful with the Wedding Kit.
Hand-Held Seal Embosser is included in
the Wedding Package and the Platinum
Package.
Desk Seal Embosser
More durable version of the hand-held
embosser, and sits on your desk.
The Desk Embosser is NOT an ocial
seal.
$44.99
Notary Public Supply Descriptions
$36.95
$31.99
Renewing?
Check your
supplies
Special Note Regarding Errors & Omissions (E&O) Insurance:
ALL of our packages include $5,000 worth of E&O Insurance protection.
We believe so strongly in your protection that we make it part of all of our packages.
Can you aord to hire an attorney to defend yourself if you make
an unintentional mistake as a Notary Public?
Consider purchasing additional protection. Here are a few examples of how small mistakes can be costly:
A Notary was sued for allegedly axing her seal to a forged signature. The judgment was rendered in favor of the Notary, BUT she still
incurred legal fees for her defense.
As an employee, a Notary, acting under instructions from a manager, witnessed signatures in a real estate transaction, which later proved to
be forgeries. This Notary was held liable for $5,000 in damages and $2,493 in court costs.
Mail Application & Order Form to: Vermost Insurance Agency • 1200 Belcher Rd S • Ste 1 • Largo, FL 33771
727-748-2886 • 800-828-2226 • www.FLNotaryPublic.com
Notary Public Package & Supplies Order Form
Review the Price Chart Attached for Item Prices
Notary Order Price Calculator
Package Description:
Package Cost
Package Promo Discount
(code required _____________)
Package Subtotal +
Add’l Supplies Description:
Add’l Supplies Price +
Add’l E&O Coverage Description:
Add’l E&O Coverage Price +
Shipping FREE
TOTAL ORDER $
NEED HELP?
Call 727-748-2886
or 800-828-2226
Promo Discount Code required for discount.
Discount applies to packages only.
If you are a Veteran with 50% Disability
Status, contact us for reduced rates.
Additional Items and Package Prices INCLUDE
Florida State & local sales taxes.
Tax exempt business, call for pricing.
Payment Check # ______________ Money Order MasterCard Visa
Card # Exp. Date
Signature: ________________________________________________ Daytime Phone #: ________________________________
Email for Special Oers & Updates: _____________________________________________________________________________
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