COMPLETE, PRINT, SIGN AND MAIL
For Office Use Only
ID Number: WO Number:
SECRETARY OF STATE
SFN 11001 (12-07)
INSTRUCTIONS: 1. For reference, see North Dakota Century Code, Chapter 44-06. 2. A commissioned Notary Public, not the applicant, must notarize your signature.
3. In compliance with the Federal Privacy Act of 1974, the disclosure of the social security number on this form is voluntary. They are not disclosed to the public. The numbers are used by the Secretary of State to maintain accurate notary files. Therefore, while voluntary disclosure is requested, failure to do so will not invalidate this notary application.
Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500 Telephone: 701-328-2901 Toll Free: 800-352-0867 Ext. 82901 Fax: 701-328-1690 Web Site: www.nd.gov/sos
4. Along with the application, submit a six-year notary surety bond in the amount of $7,500.00. (The spelling of the name on the bond must be identical to the name in box # 1.) 5. If you reside in a county which borders North Dakota, it will be necessary for you to complete an appointment of agent form. 6. After the receipt of the fee, application and surety bond, you will be issued an authorization letter, which authorizes a vendor to provide you with an official notary seal/stamp. Once an impression of your seal/stamp is affixed to the return letter, the letter must be signed and returned to the Secretary of State's Office. When the return letter is received, approved, and filed, an official notary certificate of commission will be issued to you. 1. Legal Name of Applicant: 3. Home Mailing Address: 5. Work Mailing Address: 7. Spouse's Complete Name: 9. Type of Application: Mr. Ms. E-mail Address: City: City: State: State Zip Code: Zip Code: 2. Social Security No.: 4. Home Telephone: 6. Work Telephone:
8. If applicant is not a ND resident, list your county of residence and which ND county it borders: New Appointment Re-Appointment Previous Expiration Date:
10. ALL applicants must answer the following questions. If YES, attach a written explanation and ALL legal documentation, if applicable. YES NO Have you ever been the subject of any inquiry or investigation by any agency of the state of North Dakota? Have you or has any occupational license held by you been censured, suspended, revoked, canceled, terminated or been subject to any type of administrative action in any state including North Dakota? Have you ever been convicted of or entered a plea to any criminal offense (felony, misdemeanor, or infraction), other than traffic violations, in any State or Federal Court? Have you ever been a defendant in any lawsuit involving claims of fraud, misrepresentation, coercion, mismanagement of funds, breach of fiduciary duty or breach of contract? AFFIDAVIT OF QUALIFICATIONS AND OATH OF OFFICE I, the undersigned, being first duly sworn, hereby state that I am over the age of eighteen years of age, a North Dakota resident or reside in a county that borders North Dakota and which is in a state that extends reciprocity to a Notary Public who resides in a bordering county of this state, and that I desire to become a commissioned notary public in the State of North Dakota for a period of six years. I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of North Dakota and that I will faithfully discharge the duties of the office of Notary Public according to the best of my ability, so help me God or under pains & penalties of perjury.
Applicant signature in front of a commissioned Notary Public State of______________________ County of_____________________ (Notary Seal/Stamp)
Subscribed and Sworn before me, this _____day of ______________________, ________.
Notary Public My Commission Expires:_____________________________________________