Notary Public Application
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1
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3D
T
EPARTMENT OF THE
REASURY
D
R
E
S
IVISION OF
EVENUE AND
NTERPRISE
ERVICES
N
P
A
OTARY
UBLIC
PPLICATION
P
(609) 292-9292
HONE
Important: Please read instructions on reverse side.
Complete lines 1 – 8. New Jersey Non-Residents also complete line 9. Lines 10 and 11 must be completed by State Legislator.
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1) Application type
New
Renewal (Please enter the following information from your current commission certificate)
Commission Number
/
/
Expiration Date
Name Change/
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2) Print Name
Correction
(First Name)
(M.I.)
(Last Name)
Address Change/
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3) Home Address
Correction
(Number and Street, including apartment number and rural route)
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City/Town
State
Zip Code + 4
County
/
/
4) Date of Birth
(MM/DD/YYYY)
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5) Has your commission ever been denied, suspended or revoked?
Yes
No (If yes, enclose a statement of details)
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6) Have you ever been convicted of a crime?
Yes
No (If yes, enclose a statement of details)
7) Occupation
/
/
8) Signature of Applicant
Date
New Jersey Non-Residents Only
9) Please list New Jersey Business Name and Address
Business Name
Business Address
(Number and Street, including apartment number and rural route)
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N J
City/Town
State
Zip Code + 4
New Jersey County
10) Signature of State Legislator
11) Legislative District Number
For internal use only
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