Application For Appointment As Notary Public printable pdf download

Form # A-1 (Rev. 11/12/09)

FOR OFFICE USE ONLY

Notary Public Unit

Trans. #___________________________

Office of the Secretary of the State

Acct. #____________________________

State of Connecticut

PO Box 150470

Date of Appt._______________________

Hartford, CT 06115-0470

APPLICATION FOR APPOINTMENT AS NOTARY PUBLIC

PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE COMPLETING APPLICATION

•

An applicant must be 18 years of age or older and a resident of, or have a principal place of business in, Connecticut.

•

The entire application must be filled out legibly in ink in your own handwriting. All of the questions must be answered

completely.

•

The Certificate of Character on page 2 must be filled out completely and signed by a public official or a reputable

business or professional person who must be unrelated to you and have personally known you for at least on year.

•

The Jurat on page 6 must be completed and sworn to before a notary public or other appropriate official.

Return completed application to the Office of the Secretary of the State, at the above address, with a check or money

order made payable to the “Secretary of the State” in the amount of $120.00 (non-refundable statutory appointment

fee for a 5 year term).

1. Print name in full___________________________________________________________________________________

first

middle

last

1a. Print exact name you will use as a notary public (This is your name as it will appear on your certificate and the way

you must sign when performing notarial acts).

Male

Female

______________________________________________________________________________________________

2. Present residence address_____________________________________________________________________________

no.

street

town

state

zip code

Mailing address, only if mail delivery is not available to residence address____________________________________

________________________________________________________________________________________________

List prior residence addresses for the last three years:

Street

City/Town

State

Zip Code

___________________________________________________________________________________________________

____________________________________________________________________________________________________

3. Give name and address of your principal place of business in Connecticut, or the concern with which you are

connected and in what capacity.

Business name:_____________________________________________________________________________________

Address:__________________________________________________________________________________________

___________________________________________Business Phone:_________________________________________

4. What is your occupation?____________________________________________________________________________

Application For Appointment As Notary Public

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