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Nebraska Secretary of State Business Services Division: Notary
1445 "K" St., 1301 State Capitol Bldg PO Box 95104 * Lincoln, NE 68509 (402) 471-2558 or (402) 471-4094 http://www.sos.state.ne.us
INITIAL APPLICATION FOR NOTARY COMMISSION
All applicants must be a resident of the State of Nebraska .
Please type or print legibly in black ink. Incomplete responses will cause application to be rejected.
Name: (Print your name as you wish to be commissioned.) Home street address & telephone # (include City, State, Zip): ______________________________________________________ ______________________________________________________ ( ) Return Commission to this address. Phone: Business Name, Street address, & telephone # (include City, State, Zip). Optional field--see reverse. ______________________________________________________ ______________________________________________________ ( ) Return Commission to this address. Phone: If you are bilingual, would you allow your name to be placed on a list of bilingual Notaries? ( ) Yes ( ) No.
List languages in which you are fluent: ____________________________ ____________________________________________________________
Email Address (optional for sending Newsletters and bulletins):
Have you ever had your Notary Commission revoked or suspended in Nebraska or any other state? ( ) Yes ( ) No. If "yes", please identify the state(s), the date(s) and the reason(s) for the action(s): ______________________________________________________ ______________________________________________________ (Attach additional pages if needed.) Do you qualify to be a Notary Public in the State of Nebraska? Are you 19 years of age or older? ( ) Yes ( ) No Have you ever been convicted of a felony? ( ) Yes ( ) No Have you ever been convicted of a crime involving fraud or dishonesty? ( ) Yes ( ) No Are you able to read and write English? ( ) Yes ( ) No I have taken & passed the required examination. ( )Yes ( ) No I have read & understand Nebraska Notary law. ( )Yes ( ) No
Have you previously been commissioned as a Notary Public in the State of Nebraska? ( ) Yes ( ) No. If you answered "yes", please answer the following questions. Has your name changed since your last commission was issued? ( ) Yes ( ) No. If `yes', please give previous name: _________________________________ When did your commission expire: Month _______ Day______ Year _______. Affix the impression of your seal in the space below (if available):
Notarial Oath: State of Nebraska County of ___________________ I, _____________________________________, do solemnly (swear), (affirm) under penalty of perjury, that I am a resident of the State of Nebraska; that the answers to all questions on this application are true and complete to the best of my knowledge; and I have personally completed the Notary examination based on my knowledge of Nebraska Notary law and without assistance from others; and, I do solemnly (swear) (affirm) that upon appointment, I will support the Constitution and laws of the United States and the State of Nebraska, and I will faithfully discharge the duties of Notary Public in and for the State of Nebraska according to the best of my ability.
Applicant's Signature (sign name as printed above)
X_____________________________________________________ Subscribed and (sworn) (affirmed) before me By: _____________________________________
Printed Name of Applicant
this _______ day of _______________, 20 ______
Affix Official Notary Seal (Month) (Year) __________________________________________ Signature of Notary Public SOS November 2008
Instructions for completing an Initial Notary Commission Application: Note: You must have successfully passed the Notary Examination and received written confirmation of same from the Secretary of State's Office, Business Services Division, prior to making application to be commissioned.
Be sure to answer the questions in each section (except those marked as optional). An incomplete application will be rejected. Read the following instructions carefully: Name: Please clearly print or type your name as you wish to be commissioned. This is the name we will place in our official records. You must order your Notary stamp and always sign your name using this exact name. Email Address: This is an optional field. Please indicate if you have ever had a Notary Commission revoked or suspended in Nebraska or elsewhere and the location, date, and reason for the revocation/suspension. Be specific. (Add an additional page, if needed.) Do you meet the qualifications for being commissioned as a Nebraska Notary? You must truthfully answer each question asked by indicating with a "" by the yes or no. Home street address and telephone number: Please print your street address, city, state, and zip code. Telephone number is optional. If this is the address you would like your commission certificate mailed to, please indicate by placing an ` ' in the space provided. Business Name, street address, and telephone number. Please print the business name, street address, city, state, and zip code. Telephone number is optional. If this is the address you would like your commission certificate mailed to, indicate by placing an ` ` in the space provided. If you are bilingual and are interested in having your name placed on a list of bilingual Notaries, please indicate your interest in providing assistance for non-English speaking people who have Notary questions, by placing an ` ` in the space provided. List the language(s) you speak, read, and/or write fluently. If you have been commissioned in Nebraska in the past, please indicate by placing an ` ` in the space provided. If your name has changed since you were last issued a commission, please print your name as previously commissioned. Indicate the complete expiration date (day, month, and year) of the previous commission and affix your most recent Notary seal in the space provided. Oath: In the presence of a Notary, complete the oath by filling in the name of the county where the notarization is taking place; printing your name on the line in the oath exactly as stated above on the application form; and signing your name exactly as listed above on the application form . The Notary will then administer the Oath, print your name as the applicant to whom the oath was administered, sign his/her name, and affix his/her Notary seal. Submit this Notary Application, $15,000 Surety Bond, and $30.00 Commission fee to the Secretary of State's Office after you have received confirmation from our office that you have passed the written examination. Make check payable to: Secretary of State. We accept personal checks, money orders, and cashiers checks, but prefer that you do not send cash through the mail. Mail to: Secretary of State, Business Services Division (Notary) PO Box 95104 Lincoln, NE 68509.
SOS Revised July 2005