Commonwealth of Pennsylvania – Department of State
Bureau of Commissions, Elections and Legislation
Division of Commissions, Legislation and Notaries
NOTARY PUBLIC APPLICATION
(Revised 11/1/2014 and
effective 1/5/2015)
PRINT OR TYPE CLEARLY. FILL OUT APPLICATION COMPLETELY. Do not leave any blanks.
Use “none” or “N/A” if applicable. An incomplete application will delay your appointment.
CHECK ONE: New Appointment
Reappointment (have been a notary in Pennsylvania before)
PART I: Applicant Information (NOTE: Employer/Business contact information will be public record)
First Name
Middle Name or Initial (if used)
Last Name
Suffix (if applicable)
Date of Birth (mm/dd/yyyy)
Social Security Number (xxx-xx-xxxx)
Email Address (Optional)
Name of Employer/Business where Notary Commission will be used (Do not leave blank. If not applicable, please indicate.)
Employer/Business Street Address (P.O. Box alone is insufficient)
City
State
Zip Code
Employer/Business Telephone (include area code)
Municipality (city/borough/township)
County
Home Street Address (P.O. Box alone is insufficient)
City
State
Zip Code
Home Telephone (include area code)
Municipality (city/borough/township)
County
Part II: Education, Criminal History, Other Notary Commission History (Check or mark appropriate boxes)
YES (√)
NO (√)
I am a notary applicant for initial appointment or reappointment and I have completed a pre-approved three-hour notary public
education course within the six-month period immediately preceding this application (unless permanently exempted). Attach a copy
of your course completion certificate and retain your original. Lack of proof of education will result in application rejection.
Have you ever been convicted of or entered a plea of guilty or nolo contendere to a felony or lesser offense preceding the date of this
application? If yes, attach full details (name of court, plea or conviction, sentence and length of probation) and appropriate supporting
documents with a signed and dated personal explanation.
Have you ever resigned a notary commission or had a notary commission suspended, revoked or otherwise disciplined by the
Commonwealth or any other state/jurisdiction preceding the date of this application? If yes, attach full details and appropriate
supporting documents with a signed and dated personal explanation.
Have you ever had any other professional or occupational license suspended, revoked or otherwise disciplined?
If yes, attach full details and appropriate supporting documents with a signed and dated personal explanation.
Note that disclosing your social security number on this application is mandatory for the Department of State to comply with the requirements of the federal Social Security Act pertaining to
child support enforcement, as implemented in the Commonwealth of Pennsylvania at 23 Pa. C.S. § 4304.1(a). To enforce domestic child support orders, the Commonwealth’s licensing
boards must provide to the Department of Public Welfare (DPW) information prescribed by DPW about the licensee, including the social security number.
APPLICANT AFFIDAVIT: I am of good moral character and am familiar with the duties and responsibilities of a notary public. I shall furnish additional evidence of these
statements, if requested, which shall be satisfactory to the Secretary of the Commonwealth. To the best of my knowledge and belief, this application contains no
misrepresentations or falsifications, omission or concealments of material fact and the information given by me is true and complete. I understand that any false statement
made is subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities) and may result in the suspension, revocation, or denial of my notary
commission.
_____________________________________________________________________________ ________________________________________________
Applicant Signature (must match name in Part I) Date
Complete the following if you have ever been a notary in Pennsylvania before:
Notary commission expiration date
Full name on previous commission
Notary commission ID number
Other name used on previous commission
For Official Use Only
: (800) 422-1555
: (800) 224-6368
: www.notaries.com
PO Box 940489
Maitland, Florida 32794-0489
Since 1964
PENNSYLVANIA NEW AND RENEWING NOTARY ORDER FORM
1. All forms should be printed legibly.
2. Follow instructions on reverse side.
3. Total your order form and mail it with your
application and payment to:
Huckleberry Notary Bonding, Inc.
Home Oce Notary Processing
P O Box 940489
Maitland, FL 32794-0489
Notary Package: Includes Four Year State Required $10,000 Notary
Bond, State Filing Fee, Customized Self-Inking Stamp (12 colors to
choose from) and a Certificate Suitable for Framing.
Circle Stamp Color Choice:
Customized Notary Embosser Seal (4 colors to choose from)
Inkless Pocket-Sized Finger Printer to Compliment Journal
Display Sign
Shipping & Handling
All Customized Self-Inking Notary Stamps come with state required black ink.
The choice of color is for the stamp casing only and not ink.
Amount
Enclosed
Circle Seal Color Choice (If you do not choose a color, you will receive black)
Black, Pink, Blue, & Red embossers match black, pink, blue and red customized
self-inking notary stamps for a uniformed look.
Black Pink Blue Red
Black
Pink
Blue
Red
White
Green Mango
Lilac Gray Neon Pink Neon Orange Neon Green
(If you do not choose a color for your stamp, you will receive gray)
$125
$125
$40.00
$50.00
$60.00
$70.00
$80.00
$110.00
$170.00
$10.00
Record Keeping Journal for Notaries
$15.00
$35.00
$6.00
$11.95$11.95
$15.00
$10,000 Coverage
$15,000 Coverage
$20,000 Coverage
$25,000 Coverage
$30,000 Coverage
$50,000 Coverage
$100,000 Coverage
+
+
+
REQUIRED ITEMS DESCRIPTION
(Meets/exceeds all requirements of Pennsylvania Notary Law)
Recommended Errors & Omissions Insurance Upgrade - Choose One
ADDITIONAL NOTARY TOOLS
PRICE SUBTOTAL
Notary education is required for first time applicants and renewing Notaries. Huckleberry Notary Bonding’s online Notary course is state
approved for satisfying the requirement for new notary applicants which must print, sign and return the course completion certificate in order
to be commissioned. You may fax it to us at 800-224-6368. If your order cannot be completed within 9 months of submitting your information
to Huckleberry Notary Bonding, Inc., and its subsidiaries, due to lack of information needed to complete your notary appointment/certification,
we are no longer obligated to complete your order and payment becomes non-refundable.
Online Notary Education Course Required for New and Renewing Notaries
$50.00
Black
Gray Neon Pink Neon GreenNeon Orange
Lilac
Mango
Green
White
Red
Blue
Pink
CHECK/MONEY ORDER
CARD NUMBER: EXPIRATION DATE: SECURITY CODE:
NAME ON CARD:
SIGNATURE OF CARDHOLDER:
DAYTIME PHONE NUMBER:
EMAIL ADDRESS:
*All prices are for a four (4) Year notary term as required by law.
W102016
4. We will then process it with the state. In
approximately 4-5 weeks, you will receive
your Notice to Appointee Letter and
notary bond which you must immediately
mail to us.
PRODUCT DESCRIPTIONS
CUSTOMIZED NOTARY EMBOSSER SEAL
$
35
Our hand-held embosser seal creates a beautiful raised impression every time. This optional seal puts the
finishing touch on your notarizations and is widely recognized when used on documents going to other
states or international countries. Available in your choice of colors: black, pink, blue or red. Match it up with
a gray, pink, red or blue customized self-inking notary stamp!
NOTARY LIABILITY INSURANCE (NOTARY ERRORS AND OMISSIONS)
Notary Errors & Omissions Insurance is a critical component of any notary’s portfolio. It protects you, the
notary, against any potentially devastating financial costs of lawsuits that could result from an error you
make while acting in your official capacity as a notary. While not required, it’s necessary in today’s litigious
climate and is available at affordable rates that coincide with your notary term. Here are several E&O facts:
• It safeguards you against costly time-consuming lawsuits. Even if the suit is frivolous, you could
be faced with a large legal bill for defending yourself. Our policy covers legal fees.
• Your notary bond required by the state doesn’t protect you. This is a common misconception.
It merely protects those you notarize for. If a claim is filed against your bond, you have to reimburse
the insurance company for any payments they make on your behalf. Unless have Notary
Errors & Omissions Insurance. It provides primary protection and pays the claim first.
•
Employer policies do not protect you. No matter what you are told, you are individually responsible
for your own actions as a notary, even if you notarize only for work related purposes.
• Errors and Omissions coverage includes forgetting to affix your notary stamp to the document,
not properly identifying the person signing the document, and other simple and common mistakes.
Errors & Omissions Insurance provides you with peace of mind, protecting you against any claim for an act
or omission and personal liability while acting in the capacity of Notary Public. It also provides coverage for
all defense costs and pays from the first cent. Furthermore, you’ll have no repayment of claims back to the
insurance company. No deductible, coverage on and off the job and affordable protection. Don’t notarize
without it.
RECORD KEEPING JOURNAL FOR NOTARIES
$
15
Notaries in Texas are required to keep a record of all notarizations. Our Journal helps you keep a record of
your notarial acts and even includes a space for finger prints. Pair it up with our Inkless Finger Printer!
INKLESS FINGER PRINTER
$
10
Easy to use and no mess when used in conjunction with our Record Keeping Journal for Notaries.
It’s a great fraud deterrent.
ROUND SELF-INKING NOTARY STAMP
$
46
Our round self-inking notary stamp replaces or can be used in addition to our rectangular notary stamp.
Creates crisp/clear impressions every time.
NOTARY PUBLIC DISPLAY SIGN
$
6
Our display sign lets others know you’re a Notary.
CUSTOMIZED SELF-INKING NOTARY STAMP
$
32
Nine color choices to choose from and customized with your name, commission number and expiration
date. It’s the “gold” standard among notary stamps. Order an extra one to keep in your car, home or office.
APPLICATION INSTRUCTIONS
•
•
•
•
•
Pennsylvania Notary Commissioning Directions Please Read
• Print or type clearly. Fill application out completely. Do no leave any blanks. Use “none” or “N/A” if applicable.
AN INCOMPLETE APPLICATION WILL DELAY YOUR APPPOINTMENT.
• Select New Appointment or Reappointment (as a Pennsylvania notary). Reappointments must provide previous
commissioning information as requested on application.
PART I: Applicant Information
Complete all blanks. Your printed name must match your signature at the bottom of theapplication. If you do not use
your middle name or initial as part of your signature do not include them. Use of nicknames is not permitted. For example if your
legal name is “Joseph” you may not apply as “Joe”. (PLEASE SEE #1 BELOW)
If you include information about your employer then this is the county that your notary will be commissioned through.
If you do not want to be commissioned according to your county of employment then you may repeat your home
address in this section. You must give a physical address for your home and employment address, a PO Box will not
be accepted.
PART II: Notary Education, Criminal History, Other Notary Commission History
Answer each question “Yes” or “No”
NOTARY EDUCATION: All Pennsylvania notary applicants, both new and reappointment must complete a pre-ap-
proved, three hour notary public education course within the six-month period immediately preceding their time of
application. Pennsylvania requires applicants to complete the course in one, three hour time period. If you log out of
the course you will have to start over. When the course is completed you will print a certificate of completion which
you will sign and submit along with your completed application page. Your printed name and signature on your educa-
tion certificate must exactly match the ones on your application.
1. Sign your completed application and education certificate.
PLEASE NOTE: THE STATE OF PENNSYLVANIA REQUIRES YOU TO SIGN WITH A LEGIBLE SIGNATURE.
YOU MUST BE ABLE TO TELL THAT YOUR PRINTED NAME AND SIGNATURE MATCH. A SQUIGGLE OR
STYLIZED SIGNATURE IS NOT ACCEPTABLE. THIS IS ALSO HOW YOU WILL SIGN YOUR NAME EVERY TIME
YOU NOTARIZE A DOCUMENT.
2. MAIL THE ORIGINAL, COMPLETE AND SIGNED COPIES OF YOUR APPLICATION AND EDUCATION CERTIF-
ICATE TO OUR OFFICE. IF YOU HAVE NOT ALREADY MADE A PAYMENT THROUGH OUR WEBSITE THEN
INCLUDE YOUR NOTARY ORDER FORM AND YOUR FULL PAYMENT.
HUCKLEBERRY NOTARY BONDING HOME OFFICE
Notary Processing
PO BOX 940489
MAITLAND, FL. 32794-0489
Once we receive your application we will send it along with your state filing fee to the Pennsylvania Department of
State for commissioning.
The state will mail you your NOTICE TO APPOINTEE letter and your BLANK NOTARY BOND. THESE ARE TIME
SENSITIVE. Please mail these forms to us as soon as you receive them. Do not sign anywhere on the forms. Send
the blank documents to us. Upon receipt of them we will complete the bond and then mail it back to you along with
your notary seal and any other supplies you have ordered.
The final step is to take the completed bond to your county courthouse and become sworn in as a Pennsylvania notary
public. Failure to do this by the date indicated on your Notice to Appointee letter will cancel your notary commission
and require you to begin the commissioning process over again.
We are here for you. Any questions or comments,
please call us at 1-800-422-1555.
HUCKLEBERRY NOT
ARY BONDING INC . • TOLL FREE 800.422.1555 • [email protected]
