HOSPITAL, HOSPICE and NURSING HOME SERVICE FORM

HOSPITAL, HOSPICE and

NURSING HOME SERVICE FORM

Your Friendly Neighborhood Mobile Agent.....

Your Name

First Name Last Name

Your Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Your Email

example@example.com

Your Phone Number

- Area Code Phone Number

Patient who is the Principal of the Power of Attorney

First Name Last Name

Relationship to you:

Type of Document(s) needing to be Notarized:

Durable Power of Attorney Health Care Directive Transfer of Deed Power of Attorney for Bank: certain Banks have their own POA Last Will and Testament Marriage Packet/Wedding Officiant at Hospital

Additional Details, Other Services or Questions:

As the Notary Public completing this certificate above. I verify only the identity of the individual(s) who signed the document to which this certificate is attached to and not the truthfulness, accuracy, or validity of that document. You will be charged for each signature(s) that sign the document that requires the above Certificate: either if its just one signer, two signers or more.

Signers Must Have Identification Cards: For a smooth transaction, please be sure that your loved one, the patient , has their current identification card
(preferred if unexpired) , i.e. State Driver's License, State ID Card or Passport. Notary public must be able to properly identify the signer of the documents before the documents can be notarized.

Name of Hospital or Nursing Facility

Room Number

Address of Facility

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

As the Notary Public completing this certificate above. I verify only the identity of the individual(s) who signed the document to which this certificate is attached to and not the truthfulness, accuracy, or validity of that document. You will be charged for each signature(s) that sign the document that requires the above Certificate: either if its just one signer, two signers or more.

Prefer Method(s) of Contact

Phone Text Email

All information is held strictly private. I do not lend, sell, trade, or give away your private information to any vendor, person, or organization of any kind. I respect your privacy!

Zekes Multi-Services

ZekesMobileNotary@yahoo.com

(833) 683-4637

(There will be a Credit Card Processing Fee)

NO REFUNDS FOR NOTARY SERVICES RENDERED AND COMPLETED WITHIN A TIMELY MANNER AND OR FOR ANY DEPOSITS PAID TO HOLD A DATE AND FOR TIME FOR ALL PROFESSIONAL SERVICES PROVIDED IN GOOD FAITH.

IF IT IS FOUND THAT I MADE AN HONEST MISTAKE, I WILL REDO YOUR NOTARY FOR FREE.

A STATE ISSUED PHOTO I.D. AND THUMB PRINT IS REQUIRED FROM ALL SIGNERS.