BOND NUMBER AFFIX CORPORATE SEAL HERE

Last Name: First Name: Middle Name or Initial:

Business Address (P.O. Box not acceptable): Street: City: State: ZIP Code:

Name of Employer: Driver’s License or State Identification Card Number (must attach a photocopy):

Business Phone: Date of Birth: Applying for: New Commission Renewal of CommissionCurrent Expiration Date: Commission Number:

Email Address: Home Phone: County of Residence:

Current Home Address (P.O. Box not acceptable): Street: City: State: ZIP Code:

Has your name, address or county changed since your last commission? Yes No If, yes, give previous name, address and/or county:

NOTARIAL OATH1. I am a U.S. citizen or an alien admitted for permanent residence.2. I have been a resident of Illinois for at least 30 days.3. I am age 18 or older.

State of Illinois, County of 4. I have never been convicted of a felony.5. I am able to read and write the English language.6. I have never had a notary public commission revoked.

Printed Name as you want Commissioned:

Signature of Applicant as Printed Above

Notary Public Signature:

Witnessed and Affirmed this day of , 20

NOTARY PUBLIC BONDTHIS BOND MUST BE WRITTEN BY A COMPANY QUALIFIED WITH THE ILLINOIS DEPARTMENT OF INSURANCE TO WRITE SURETY BONDS IN THE STATE OF ILLINOIS. The Office of the Secretary of State does not recommend any particular bonding or insurance company.

Know all by these presents that we as principal/applicant and

are held firmly bound unto the People of the State of Illinois, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators and assigns jointly and severally, firmly by these presents.

THE CONDITION OF THE ABOVE OBLIGATION IS SUCH THAT, whereas, the above bound principal/applicant has applied for appointment by the Secretary of State of the State of Illinois as a Notary Public for a four-year term.

Now, if said principal/applicant shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective date of the principals’s/applicant’s commission to the expiration date of the same.

x Notary Public Applicant

x x

x

12-681 --

AFFIX NOTARY SEAL IN BOX BELOW

PRINT APPLICANT'S NAME HERE

WEST BEND MUTUAL INSURANCE COMPANY

Notary Public Application Jesse White — Illinois Secretary of State

I do solemnly affirm, under the penalty of perjury, that the answers to all statements on this application are true, complete and correct; that I have carefully read the notary law of the State of Illinois; and that if appointed and commissioned as a notary public, I will perform faithfully, to the best of my ability, all notarial acts in accordance with the law. Further, my signature below authorizes the Office of the Secretary of State to conduct a background verification to confirm the assertions and information provided herein.

•

West Bend Mutual Insurance Company, 8401 Greenway Blvd, Ste 1100, Middleton, WI, 53562

RETURN UPON COMPLETION TO: Notary Public Association, PO Box 1101, Crystal Lake, IL 60039-1101COPY OF YOUR IL DRIVERS LICENSEOR IL STATE ID MUST BE ATTACTED TO THIS APPLICATION

WE ARE NOT ASSOCIATED WITH ANY STATE OR LOCAL GOVERNMENT AGENCY

RETURN UPON COMPLETION TO: Notary Public Association, PO Box 1101, Crystal Lake, IL 60039-1101

NOTARY PUBLIC BOND

NOTARIAL OATH

GENERAL INFO

APPLICATION INSTRUCTIONS

1

2

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4

5

6

7

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8

The first & last name must match the name on your driver’slicense.If you do not have a business address please write n/a orself-employed.Every applicant must include a legible copy of his or herdriver’s license or state id.Please note: Failure to include a legible copy will result inrejection of you application by the Secretary of State’soffice.Include at least one phone number.

State your county of residence, as this is where you will beregistered. Your business county cannot be used.

State your home address. Your home address must match yourdriver’s license, unless you have changed it on the Secretary ofState’s website.

Your name as written on your driver’s license printed (1st line) andyour signature (2nd line) must read exactly the same.Please note: Your signature must be original.

Your signature from #7 (above) must be notarized byanother current Illinois Notary Public, including a valid rubberstamp seal. You cannot notarize your own signature. Please note: Notary’s signature must be original.

Print your name.

Sign your name as you signed it in #7Please note: Your signature must be original.

BOND NUMBER AFFIX CORPORATE SEAL HERE

Last Name: First Name: Middle Name or Initial:

Business Address (P.O. Box not acceptable): Street: City: State: ZIP Code:

Name of Employer: Driver’s License or State Identification Card Number (must attach a photocopy):

Business Phone: Date of Birth: Applying for: New Commission Renewal of CommissionCurrent Expiration Date: Commission Number:

Email Address: Home Phone: County of Residence:

Current Home Address (P.O. Box not acceptable): Street: City: State: ZIP Code:

Has your name, address or county changed since your last commission? Yes No If, yes, give previous name, address and/or county:

NOTARIAL OATH1. I am a U.S. citizen or an alien admitted for permanent residence.2. I have been a resident of Illinois for at least 30 days.3. I am age 18 or older.

State of Illinois, County of 4. I have never been convicted of a felony.5. I am able to read and write the English language.6. I have never had a notary public commission revoked.

Printed Name as you want Commissioned:

Signature as you wantto be Commissioned

Notary Public Signature:

Witnessed and Affirmed this day of , 20

NOTARY PUBLIC BONDTHIS BOND MUST BE WRITTEN BY A COMPANY QUALIFIED WITH THE ILLINOIS DEPARTMENT OF INSURANCE TO WRITE SURETY BONDS IN THE STATE OF ILLINOIS. The Office of the Secretary of State does not recommend any particular bonding or insurance company.

Know all by these presents that we as principal/applicant and

West Bend Mutual Insurance Company, 8401 Greenway Blvd, Ste 1100, Middleton, WI, 53562 are held firmly bound unto the People of the State of Illinois, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators and assigns jointly and severally, firmly by these presents.

THE CONDITION OF THE ABOVE OBLIGATION IS SUCH THAT, whereas, the above bound principal/applicant has applied for appointment by the Secretary of State of the State of Illinois as a Notary Public for a four-year term.

Now, if said principal/applicant shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective date of the principals’s/applicant’s commission to the expiration date of the same.

x

x x

x

12-681 --

AFFIX NOTARY SEAL IN BOX BELOW

PRINT APPLICANT'S NAME HERE

WEST BEND MUTUAL INSURANCE COMPANY

Notary Public Application Jesse White — Illinois Secretary of State

I do solemnly affirm, under the penalty of perjury, that the answers to all statements on this application are true, complete and correct; that I have carefully read the notary law of the State of Illinois; and that if appointed and commissioned as a notary public, I will perform faithfully, to the best of my ability, all notarial acts in accordance with the law. Further, my signature below authorizes the Office of the Secretary of State to conduct a background verification to confirm the assertions and information provided herein.

A COPY OF YOUR IL DRIVERS LICENSEOR IL STATE ID MUST BE ATTACTED TO THIS APPLICATION****WE ARE NOT ASSOCIATED WITH ANY STATE OR LOCAL GOVERNMENT AGENCY****

Doe Jane A

1014 Riley Way Winston IL 61234

Jayden World D123-4567-8910

(555) 555-5555 6/10/1990 n/an/a

customerservice.npa@gmail.com (111) 111-1111 Cook

1227 Callie Court Normal IL 67890

Cook

Jane A. Doe

Jane A. Doe

31 October 16

Notary Public Applicant

1

2 34

56

7

8

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10

8

MAILING INFORMATION

BECOME ANOTARY

RENEW AS ANOTARY

E&OINSURANCE

NOTARYSUPPLIES

NOTARY PUBLICASSOCIATION

Serving Illinois Notaries Since 1988

Notary Public Association PO Box 1101 Crystal Lake, IL 60039-1101 (815) 455-4247 info@notarypublicillinois.com

MAILING ADDRESSNotary Public Association

P.O. Box 1101Crystal Lake, IL 60039-1101

• Completed and signed application• A legible copy of your IL driver’s license or IL state ID• Online order confirmation

ONLINE ORDERSPlease mail the following:

• Completed and signed application• A legible copy of your IL driver’s license or IL state ID• Completed order form with full payment (your payment

should reflect the amount you wrote on your order formunder “Total Amount Enclosed”)

MAIL IN ORDERSPlease mail the following:

Please make checks and money orders payable to: Notary Public AssociationPay to: Notary Public Association $

CHECK