A. Fill out this section completely. Do not use whiteout to correct mistakes. If necessary, line-through any mistakes.
B. Write ‘N/A’ or ‘Self Employed’ for business address, if none.
C. IMPORTANT: Include a legible photocopy of your valid Driver’s License or state identification card, front and back. Your home address must match your Driver’s License. If you have registered a change of address online, please note. If you need to update your address, visit http://cyberdriveillinois.com/.
D. Provide an email address (for correspondence from the state).
E. Provide at least one phone number.
F. Print your county of residence, not business.
G. Print your name exactly as you want it to appear on your commission certificate.
H. In the presence of a Notary, sign the notarial oath. Signature must match printed name.
J. Sign your name here, as shown on your Driver’s License, as you are the Principal/Notary Public Applicant.
K. Leave this blank. The Bond Number will be completed by our office.
