NAC240.266. Nonresident applicant for appointment as notary public: Form of affidavit for self-employed applicant confirming maintenance by applicant of business within State of Nevada.

The following form must be used by an applicant for appointment as a notary public who resides in an adjoining state if the applicant is self-employed:

NONRESIDENT NOTARY PUBLIC

AFFIDAVIT OF SELF-EMPLOYED APPLICANT

STATE OF.............................

COUNTY OF........................

     I, ....................(Name of Self-Employed Applicant)...................., 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 self-employed.

     3. My business, ....................(Name of Business)...................., is licensed to do business in the State of Nevada.

     4. The address of my place of business is...................................................................................

............................................................................................................................................................

     5. The telephone number at my place of business is....................................................................

DATED this..........(day) of....................(month) of......(year)

                                                                        ....................................................................................

                                                                                   Signature of Self-Employed Applicant

Signed and sworn to before me on ........(date)........by....................(Signature of Self-Employed Applicant)....................

                                                                        ....................................................................................

                                                                                             Signature of Notary Public

     (Added to NAC by Sec’y of State by R175-97, eff. 1-20-98)