*Term of address         Mr. Mrs. Ms.   Miss Dr.
*Last name                   
*First name or initial    
Middle name or initial              Suffix (Jr./Sr./etc.)

Date of birth (MM/DD/YY) //19

*Full name you will use as a notary public 

Have you ever been commissioned as a notary public in the state of Texas before?  Yes     No 

Are you a legal Texas resident? Yes  No   (US citizenship is not required)

NOTE: Your Social Security number and a valid Texas driver's license/ID is required for the Texas Application for Appointment as a Notary Public. The Application will be sent to you by mail upon receipt of this form and your confidential information should be added at that time.

Have you ever been convicted of a felony, misdemeanor, or crime involving moral turpitude?
     Yes  No  (If “Yes”, stop here and call The Secretary of State, Notary Public Unit at (512) 463-5705.)

Company name (if applicable) 

     Type of business 

     Department 

     Your position 

     Business mailing address (street number or P.O. box) 

     City    State         Zip

     Location of Employment (NOT P.O. box)

     City    State    County   Zip  

 Parent company name and location if the address listed above is a branch or subsidiary 

E-mail address 

*Daytime telephone  () - Ext.  
  Fax  () -

IMPORTANT--We DO NOT sell or release our customers' fax numbers to others!!

Evening telephone  ()-

Residence address (NOT P.O. Box) 

City    State    *County   
Zip   

How did you learn about Atkinson Bros. Agency and this website (radio, fax, friend, employer, other website, etc.)?

Notary Package Options

If you are not commissioned as a notary, or if your commission is not renewed, all moneys will be refunded upon written request. The Basic Individual Notary Package includes:

-- $10 Texas State filing fee
-- Self-inking notary stamp/seal
-- Full-sized notary record book
-- Texas Notary Public Handbook 
-- $10,000 4-year notary bond (required by law) with $35,000 professional liability protection

Select a Notary Package

Basic Individual Notary Package $159.50
Notary License Package $99.50 (DOES NOT include professional liability coverage**)
      **REQUIRED: Accept or decline liability coverage  
      I ACCEPT professional notary liability coverage
      I DECLINE professional notary liability coverage

NOTE: EMPLOYERS--To purchase group liability coverage for new and existing notaries, call us at (800) 929-6093.

Payment Options
If you are not commissioned as a notary, or if your commission is not renewed, all moneys will be refunded upon written request.
Select amount $159.50 $99.50 Total amount authorized for the notary package you selected above

    I prefer to mail a check payable to Atkinson Bros. Agency at PO Box 271989, Houston, TX 77277-1989.
            (Attach your check to this side of printed form and send by US mail.)

    Please charge payment to my: VISA   MC   DISC   AMEX                   

 Last 4 Digits of Account Number  * 
*For your security please provide only the last four digits of your Credit Card Number or leave the field blank and telephone us with the credit card number. Billing address and zip code (below) are required.

     Exp.  Month January February March April May June July August September October November December Year 2007 2008 2009 2010 2011 2012 2013 2014 2015    
    Name as shown on card 
    *Billing address             
                                        
     Authorized signature if not submitting online
     Date authorized  (MM/DD/YY) //

Submission Options

- Print this completed form for your records. -

-THEN-

- Fax your completed form to (713) 664-8156 or  (800) 929-6094 -

-OR-

- Mail your completed form to P.O. Box 271989, Houston, TX 77277-1989 with check or money order. -

-OR-

- Click the Submit button at the bottom of this form. -

To retain a copy of your completed form for your records, use the PRINT or SAVE buttons in your browser before submitting.

                       

No password is required to submit this form. 
If you are prompted to provide a password, please contact us immediately at 1-800-929-6093.
                                                                                                   Form No. NAQNSRCE.01B