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Identification Number New Renewal 9) Your Date of Birth 8) Your County of Residence DEPARTMENT OF THE TREASURY DIVISION OF REVENUE NOTARY PUBLIC APPLICATION PHONE (609) 292-9292 Important: Please read instructions on reverse side. Renewal and new applicants must answer every question (1-11). Complete all items on this form and have it signed by a State legislator. 1) Have you ever been convicted of a crime? ___yes ___no 10) Signature of Legislator (If yes, enclose a statement of details) 2) Have More____ yes ____no (If yes, enclose a statement of details). 5) Set forth your occupation. Print Full Legal Name. 6) Signature of Applicant. Street Address. 7) Date Less
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