Free Commonwealth of Virginia - Virginia

Commonwealth of Virginia Secretary of the Commonwealth

Application for Appointment as Notary Public
_______________________________________________________________________
Instructions:
1. 2. 3. PRINT LEGIBLY OR TYPE ALL ANSWERS. APPLICATION MUST BE COMPLETED FRONT AND BACK. All questions must be answered or the application will be returned. Make check or money order for $45.00 payable to the Treasurer of Virginia. Each application must be accompanied by a check. Checks must note the name(s) of each applicant on the face of the check. Return this application completed in full with your check or money order to: Notary Clerk, Office of the Secretary of the Commonwealth, P.O. Box 1795, Richmond, VA 23218-1795.

Part 1: (Please circle one: Male, Female) (Please circle one: New Applicant, Renewal) 1. Name: _________________________________________________________ If renewing, is this a name change? Yes No
As your commission will read (Must be the same as the name on your state issued ID)

2. ____________________________________________3. Date of Birth: _______/_________/________________
*Notary Registration Number* Number & Street or Post Office Box mm City/Town dd State yyyy Zip Code

4. Home Address: __________________________________________________________________________________________ If renewing, is this home address a new address? Yes No 5. Please Check One (If Applicable): Unemployed ________ Retired ________ Student _________ Self-Employed ________ 6. Present Employer (If Applicable): ___________________________________________________________________________ 7. Business Address: ________________________________________________________________________________________
Number & Street or Post Office Box City/Town State Zip Code

If renewing, is this business address a new address? Yes No 8. Preferred Mailing Address (Please Check One): Home_______ or Business_________ 9. (______) _________________________10. (_____) _____________________ 11. (______)______________________________
Home Telephone Number Work Telephone Number Cell Phone Number

12. __________________________________
Circuit Court in which you wish to receive your commission.

13. Please Check: Yes No Are you at least 18 years old? Do you read and write English? Have you ever been convicted of a felony? Failure to answer this correctly will subject you to criminal penalties and automatic revocation of your commission. Provide Date(s), Court(s), and Offense(s) for each felony conviction, If yes: _______________________ _______________________ ____________________________
Date(s) of Conviction(s) Court(s) Offense(s)

Have your Civil Rights been restored by a Governor following felony conviction(s)? If yes, please provide documentation of your Restoration of Rights with your application. Are you currently serving as a Notary Public in Virginia? The Certificate evidencing your appointment as Notary Public contains the following words: "... in the year of our Lord..." If you would like to have these words omitted from your certificate, check this box.

Part 2: Please put your initials next to each statement indicating that you understand the information provided. _____ A Virginia Notary Public must be familiar with and understand everything contained in "The Handbook for Virginia Notaries Public." The handbook is located on the following website: http://www.commonwealth.virginia.gov/OfficialDocuments/Notary/notary.cfm _____ A notary must always be completely satisfied with the identity of the person whose signature is being notarized. A notary is not obligated to notarize a person's signature without being sure that the person is who he or she claims to be. Always check identification and be satisfied that the identification is valid. Never accept the word of a third party as being sufficient for identification to justify notarizing a person's signature. _____A notary is not required to charge a fee for his or her services, but if a fee is a charged; it cannot be for more than $5.00 for each document notarized. _____A notary is not authorized to perform marriages or certify birth, marriage or death certificates nor any act that constitutes the practice of law. _____A notary must provide the following items on each document notarized: 1. The name of the county or independent city in which the document is signed. 2. The date it is signed. 3. Notary's statement 4. The notary's signature 5. The date the notary's commission expires 6. The notary's registration number 7. A seal or stamp _____A notary must not notarize a signature that is on a different page than the notary statement without the proper certificate wording on the same page as the signature. _____A notary must notify the Secretary of the Commonwealth's Office with any changes to the information provided on this application. _____If there are any changes to the notary law, the information will be available by July 1 of every year on our website http://www.commonwealth.virginia.gov/OfficialDocuments/Notary/notary.cfm or by calling the Secretary of the Commonwealth' Office.

Part 3: I the undersigned Applicant do hereby swear (or affirm) that the information supplied herein is true and complete, to the best of my knowledge and belief. Signature of Applicant ________________________________________________________________________________________
(This signature must match the name used in signing ALL notarized documents)

City/County of ____________________________________ State/Commonwealth of ____________________________ Acknowledged and sworn to before me this ___________ day of __________________________________, 200_____

______________________________________________________
Signature of Virginia Notary or other officer authorized to administer oaths

_________________________________
Expiration Date

______________________________________________________
Notary Registration Number (or official title if not a notary)

NOTE: By law, you must claim your commission within 60 days after it is issued. If you fail to do so you must submit a new application and a new fee to become a Notary. If you have not received a notice of your commission within four weeks call the Secretary of the Commonwealth's Office at (804) 692-2536 or by emailing to [email protected] Sometimes notices are lost in the mail. Failure to receive a notice will not permit you to receive a commission after the 60-day period has expired.
*The Commonwealth of Virginia requests that each Notary Public Applicant submit a Social Security Number on a voluntary basis. This number is used as a unique number for the applicant and recipient identification in processing forms for application and appointment. (Public Law 93-579, referred to as the Federal Privacy Act, became effective September 27, 1975. Section 6(b) of this law requires that any Federal, State or Local Agency which requests an individual to disclose his/her Social Security Number inform the individual whether that disclosure is mandatory or voluntary, by which statutory or other authority the number is solicited, and what uses could be made of it.)*

Revised June 2008