§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

 

(Source:  Added at 47 Ill. Reg. 8640, effective June 5, 2023)