161885 07/23/2008 a CITY OF CARMEL, INDIANA VENDOR: 279200 Page 1 of 1
ONE CIVIC SQUARE INDIANA SECRETARY OF STATE
CARMEL, INDIANA 46032 NOTARY DEPARTMENT CHECK AMOUNT: $5.00
ROOM 201, STATE HOUSE CHECK NUMBER: 161885
INDIANAPOLIS IN 46204
CHECK DATE: 7/23/2008
DEPARTMENT ACCOUNT PO NUM BER I NVOICE N UMBE R AMOUNT DESCRIPTION
1160 4355300 5.00 ORGANIZATION MEMBER
I VV
Do Not Write In This Box For Office Use Only
Commission Expiration Date of New Commission
APPLICATION FOR APPOINTMENT AS A NOTABLY PUBLIC IN THE STATE OF INMANA
Complete and Return to: Notary Department, Secretary of State, Room 201, State House
Indianapolis, Indiana 46204; Telephone: 317.232 -6542
To, THE GOVERNOR OF INDIANA
1 respecNully request that I be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond,
oath of office, and fee of FIVE DOLLARS ($5), payable to the Secretary of State, in the form of a check or money order (Do not send currency In
the mail.) (IC 33- 16 -2.1)
PRINT OR TYPE
I, NAME v��Je12LLL /'1/ORR /f
Ywr IDOW afgn�uro IR„WhIa �Omnnission v4I be Issued see Inencdon X13
2. HOME ADDRESS J..i� L ND U C K o�C
Numtrerendetreet
C17RAAEL
d ry i State „~XX, TIP wdo
3. COUNTY OF RESIDENCE
4. Business or Employer's Name
5, Business or Employer's Address QJ(/&- C lUlG U197? 31*z D l f z c, 1 V W
r7 street City state ZIP coda
a. HOME PHONE 2 W 0 006 OFFICE PHONE y ��l
Area Code Ntmber Arse Code Numbor
7. If you have a current volf notary commission, show your expiration date:
S. If you are now as notary public and your name or county has changod since your last application, please give both old and new information.
OLD W ?l TL (5 K COUA Z?VO119WfJ
NEW: /7t C TUN Co v _zW1 -J 14��
9. NOTARIAL OATH
STATE OF INC) IANA j SS!
COUNTY OF /r
co unty in which oath m n red
I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of Indiana; that I am duly
qualified to hold office under the Constitution and laws of the State; that I am 18 years of age or over, that I am of good moral character and Integrity;
that I am a resident of Indiana; that my answers to questions on this application are true and complete to the best of my knowledge; that I have
carefully read all of the instructions which came with this application, and that I will faithfully d impartially discharge the duties of NOTARY
PUBLIC If so commissioned by the Governor, according to the best of my skill and ability, so hel s God (or undeXth =and penalties of
perjury).
Signal= a applhant
Plato oNlcor's Soal H*ro Subscribed and sworn or affirmed to before mug, this day of
A:). 20 0_ IN TESTIMONY WHEREOF, I, S has' r ✓t
PAnted or typed name or otrletu
a
/9':) Aw e for the
Slp of a notur bUc or etlar orrlcar sUQWZad to edminleter onths omea
Cau ty of Al State of Indiana,
ncorc noun of r"IdenOu
My commission expires; Su e— a:?
NOTE: Ths Bond Form, starting with #10 on the back of this application, must be completed before mailing to the Secretary of State.
The applicant must sign again in #10.
NEO 0697 IN (1103)
rr.0 iu cuuo rai uo- io nil n, j, opler vo, inc, rnn IYU, of t0400ouu r, ut
y
10. NOTARIAL BOND 'IN
Bond No.
KNOW ALL BY THESE PRESENTS, that we /�D�S'
as principal
tv4me of AppUcant
(applicant) and Merchants Bonding Company (Mutual) of
2100 Fleur Drive wm, d Surely Des Moines, Iowa 50321 -1158 and Polk County as
Street adchm, city, state a ZIP code
freehold or corporate surety, are held and firmly bound unto the State of Indiana, in the penal sum of FIVE: THOUSAND DOLLARS ($5,000), the
payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, firmly by these presents.
WITNESS our signatures as acknowledged below. THE CONDITION OF THE ABOVE OBLIGATION IS AS FOLLOWS,
TO -WIT.
WHEREAS, the above bound principal has applied for appointment by the Governor of the State of Indiana as a
Notary Public, in and for the State of Indiana, for a eight -year term,
Now, if the, said princlpal shall truly and faithfully perform and discharge the duties of said office of Notary Public, In all things according to
law, then the above obligation to be null and void otherwise to remain in full force and virtue In law. The tern of this bond is from the effective
date of the princip commission to the Ion date of the same,
elgneture or nPPAoaM, Must be edmowledgad below In qt t sloneture of surety. Must be irlaiowredped blow In 012
11, ACKNOWLEDGEMENT OF APPUCANTS SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS
STATE OF n c-- COUNTY OF 2V! rni h SS:
County in Mallon gdmowWpwwl It twlnp ntado
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc,) personally appeared
!/Cc r re i D N o/' i 5 and acknowledged the execution of the foregoing bond for the uses and
Pdntod or �r�od name of appileen
purposes therein expressed, without condition or reservation.
Place smtroe seal here IN TESTIMONY WHEREOF, I .l P l7 h N b. c Aa /7 have hereunto set my
POI)ted or lyped name of officor
hand and official seal, this day of iTLr 1 v 20 0,_
e Cf n�u rN
S elure of suvoued ornow o cO
for the County o z rn i /fin State of
OfAcetb munN oirr>alderxlo
�T
My commission expires: c n e a _10 /„c
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Corporate) BY A PUBLIC OR OTHER OFFICER
AUrHORIZE0 BY LAW TO TAKE ACKNOWLEDGEMENTS (NOTE. The officer cannot acknowledge his/her own signature)
STATE: OF COUNTY OF
SS:
county In wrim ecW"ddgement Ir. bolnp mado
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared
and acknowledged the execution of the foregoing bond for the uses and
Printed or piped nom of Indmdwal 9*8 os surety
purposes therein expressed, without condition or reservation.
Plea Ofnoars rxal hero IN TESTIMONY WHEREOF, P have hereunto set my
dntod or typed nenta of oftkxr
hand and official seal, this day of 20
sipnaturc authortzed omcar a
emw
for the County of State of
OtHWO county W reddnnco
My commission expires:
For the statute pertaining to surety company bonds, see Indiana Code 27 -1 -22. For the statutes pertaining to Officer's Bonds and
is. son Inriiana rniqob R.d
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
7/21/08 CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Secretary of State Purchase Order No.
Room 201, State House Terms
Indianapolis, IN 46204 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
7/9/08 Notary processing fee for Darrell Norris $5.00
Total $5.00
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
Secretary of State IN SUM OF
Notary Dept /Room 201 /State House
Indianapolis IN 46204
5.00
ON ACCOUNT OF APPROPRIATION FOR
1160 Mayors 4355300
Organization Membership Dues
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Stmt 4355300 $5.00 bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
20
A Sign ure
r
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund