January 30, 2006 - Pennsylvania Electronic Notarization Initiative

Application to Become a Pennsylvania Electronic Notary

In order to obtain approval from the Department of State to act as an electronic notary, you must first be a duly appointed and commissioned notary public in the Commonwealth of Pennsylvania, holding a current and unrestricted commission. DO NOT apply for approval as an electronic notary if you fail to meet this requirement. If you are not currently a notary public in Pennyslvania click here. Please contact us if you require further assistance, 215-563-8190 or visit our website at notariesequipment.com.

General Instructions

• This application must be typewritten or printed legibly and all questions must be answered completely. Complete all blanks in the application, placing “n/a” or “none” if applicable. While the fields of this application may be completed using a computer, it must be printed out and mailed to the Department, together with the required fee.
  
  
• Use your name and business address as they appear on the notary public commission records of the Department of State.
  
  
• Use your notary commission ID number as it appears on your notary commission issued by the Department of State.
  
  
• Applications will be accepted only on the form approved for use by the Secretary of the Commonwealth.
  
  
• All answers are subject to investigation and false statements will be deemed as adequate grounds for rejection. Please be advised that a felony conviction or a plea of guilty or nolo contendere or a commission revocation in the Commonwealth or any other state within the last five years prior to application will result in application rejection.
  
  
• Each application must be accompanied by a check or money order for $40.00, made payable to the “Commonwealth of Pennsylvania,” and mailed to the Bureau of Commissions, Elections and Legislation, Notary Division, 210 North Office Building, Harrisburg, PA 17120. The fee is non-refundable.
  
  
• All correspondence from the Department of State concerning your electronic notary public application and approval will be mailed to the business address as it appears on your notary public commission.
  
  
• All notifications from the electronic notary seal provider will be sent to the email address you have provided on your application.
  
  
• Upon approval as an electronic notary, the Department of State will send the applicant an Electronic Notary Approval Letter. The applicant will be contacted by the electronic notary seal provider and must complete the process for downloading an electronic notary seal within 45 days of the date the Electronic Notary Approval Letter is issued or the approval becomes null and void.
  
  
• The Secretary may, for good cause, reject any notary public application subject to the right of appeal.

PART I:

Last Name

First Name

Middle (If Used)

*Social Security Number
- -

Date of Birth (XX / XX / XXXX)
/ /

Male
Female

Notary Commission ID Number

Commission Expiration Date (XX / XX / XXXX)
/ /

Email Address

Business Name

Business Address (A business address is required and is a public record)

County of Business

Municipality

City

State

Zip Code

Business Phone (Include area code)

Home Address

City

State

Zip Code

County of Residence

Municipality

Home Phone (Include Area Code)

PART II:

Please answer the following questions

YES

NO

1

Criminal History:   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 and/or do you currently have any criminal charges pending and unresolved in any court?
    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.

2

Notary Commissions and Discipline in Other States:   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 and/or do you face any pending discipline of your notary commission by the commissioning authority of this Commonwealth or of any other state?
    If "yes," attach full details and appropriate supporting documents with a signed and dated personal explanation.

3

Other License Discipline:   Have you ever had any other Department of State license suspended, revoked or otherwise disciplined and/or do you have any pending actions against any Department of State license?
   If "yes," attach full details and appropriate supporting documents with a signed and dated personal explanation.

APPLICANT AFFIDAVIT:
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 shall furnish additional evidence of these statements, if requested, which shall be satisfactory to the Secretary of the Commonwealth. 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 or revocation of my notary commission or denial of approval as an electronic notary. I verify that this form is in the original format as supplied by the Department of State and has not been altered or otherwise modified in any way. I am aware of the criminal penalties for tampering with public records or information pursuant to 18 Pa. C.S. §4911.

________________________________________     __________________
Notary Public Signature                              Date                

*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.