Identification Number Commission Date …

Identification Number Commission date expiration date New RenewalDEPARTMENT OF THE TREASURY DIVISION OF REVENUE NOTARY PUBLIC APPLICATION PHONE (609) 530-64008) Your County or Residence 9) Your date of BirthImportant: Please read instructions on reverse side. renewal and new applicants must answer every question (1-11). Complete all items on this formand have it signed by a State ) Have you ever been convicted of a crime? ____yes ____no(If yes, enclose a statement of details)2) Have you ever been a Notary Public in New Jersey ____yes ____noIf yes, under the name of3) expiration date of Your Current Commission (If Applicable) _____4) Has Your Commission Ever Been Denied, Suspended or Revoked? 10) Signature of Legislator 11) District_____Current Commission Number _____ yes ____no (If yes, enclose a statement of details)5) Set forth your occupation Print Full Legal Name6) Signature of ApplicantStreet Address7) date City State

Identification Number Commission Date Expiration Date New Renewal DEPARTMENT OF THE TREASURY DIVISION OF REVENUE NOTARY PUBLIC APPLICATION

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