Notary Public Appointment Form
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1
2KANSAS SECRETARY OF STATE
NO
Notary Public Appointment Form
62-01
A. Personal Information
(PLEASE PRINT)
(1) Applicant Name: _________________________________________
Print
Reset
(Initials and prefixes are not allowed - see instructions)
(2) Residential Address: ______________________________________
Please complete the form, print, sign and
Street Address (P.O. Box is not acceptable)
mail to the Kansas Secretary of State with
______________________________
___________ __________
the filing fee. Selecting 'Print' will print the
City
State
Zip
form and 'Reset' will clear the entire form.
(3) Business Address: ________________________________________
Street Address (P.O. Box is not acceptable)
______________________________
___________ __________
Do not write in this space.
City
State
Zip
(5) Daytime telephone number: (____) _________________
(4) Affix an impression of applicant’s seal.
(6) Secondary telephone number: (____) _______________
(7) Give expiration date of most recent Kansas appointment:
_________________
____________
__________
Month
Day
Year
B. Oath
I do solemnly swear that I am a resident of the state of Kansas, or a resident of a bordering state who regularly carries on a business or
profession or is regularly employed in the state of Kansas; that I am over the age of 18 years and am able to read and write the English
language; that I will support the Constitutions of the United States and the state of Kansas; that I have not been convicted of a felony or
had a professional license revoked; and that I will faithfully discharge the duties of the office of Notary Public according to the law. So
help me God.
(8) _____________________________________________
}
(9) State of ____________________________
Applicant signature
ss.
County of __________________________
(10) Signed and sworn to before me this ______ day of _________________, _________
Month
Year
(SEAL)
(11) My appointment expires:_________________ ________, ________
Month
Day
Year
(12) _____________________________________________
Notary’s signature
C. Notary Surety Bond
Know All Persons By These Presents: That we, the above-named applicant as principal and
(13) _________________________________
_______________________
________________
______
_________
Name of Surety Company
Address
City
State
Zip
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 seven thousand five hundred dollars ($7,500) 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 Kansas, to hold office
for the term of four years in accordance with the 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. Further, we, the surety company, understand that
we are required by K.S.A. 53-120 to report to the secretary of state the outcome on any claim filed on this bond.
___________________________
(14) _____________________________________________
Surety
Date
Rev. 1/27/11 jdr
K.S.A. 53-103
1/2
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