14 Ill. Adm. Code 176.ILLUSTRATION A
A Nonresident Notary Public Affidavit of Applicant
Section 176.ILLUSTRATION A:
Nonresident
Notary Public Affidavit of Applicant
NONRESIDENT NOTARY
PUBLIC
AFFIDAVIT OF
APPLICANT
STATE OF
COUNTY OF
I, (name), being first duly sworn, state upon personal
knowledge and under penalty of perjury as follows:
1. The address of my residence is:
2. I am employed by:
3. The address of my employer is:
4. The telephone number at my place of employment is:
5. The email address at my place of employment is:
6. The web address at my place of employment is:
Dated this
day of
, 20
Signature of Applicant:
Signed and sworn before me on
day of
, 20
By
(Printed Name of Applicant)
(seal)
Signature of Notary Public