*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

*Are you currently a notary public for the State of Illinois?  Yes  No
    If yes, when does your commission expire?    Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2002 2003 2004 2005 2006 2007 2008 2009 2010
    If yes, what is your commission number?    

*Name you (will) use as a notary public 
    List previous notary name, if any:
    List previous address, if any:
 

*Are you a U.S. citizen or an alien admitted for permanent residence? Yes  No

*Have you been a resident of Illinois for at least 30 days?  Yes  No

*Are you able to read and write the English language?  Yes  No 

Have you ever been convicted of a felony?
     Yes  No
    (If  yes, please contact the Illinois State Notary Office at (217) 782-7017 before submitting your application.)

Have you had a notary commission revoked within the last ten years?  Yes  No 

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)  
     Street number
     City    State    
     County       Zip  

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

E-mail address 
    IMPORTANT--We DO NOT sell or release our customers' e-mail addresses to others!!

*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 Notary Package includes:

-- $10 Illinois State filing fee
-- Self-inking notary stamp/seal
-- Full-sized notary record book
-- $5,000 4-year notary bond (required by law) with $105,000 professional liability protection

Select a Notary Package

Basic Package $484.50 ($105,000 professional liability limit)
Package II $276.50 ($55,000 professional liability limit)
Package III $172.50 ($30,000 professional liability limit)
Package IV $153.00 ($20,000 professional liability limit)
Package V $133.50 ($15,000 professional liability limit)

NOTE: The totals for each notary package DO NOT INCLUDE the $5.00 or $10.00 fee assessed by the County Clerk's Office when you pick up your certificate. For additional information about pricing for other liability limits and express delivery options, please refer to the Illinois Notary Information page or call us at (800) 929-6093.

Payment Options

Select amount $484.50 $276.50 $172.50 $153.00 $133.50 Total amount authorized for the notary package you selected above

    I prefer to mail a check payable to Atkinson Bros. Agency is enclosed. 
            (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 2006 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. NAQAIL01.WWW