STATE OF SOUTH CAROLINA OFFICE OF THE SECRETARY OF STATE THE HONORABLE MARK HAMMOND Notary Division 1205 Pendleton Street, Suite 525 Columbia, SC 29201 (803) 734-2512 (803) 734-1116 Request for Duplicate Notary Public Commission or Change of Name of Notary Public The applicant is requesting the following: (Please check the appropriate box or boxes.) [ ] Duplicate Copy of Notary Public Commission (this includes pocket card) - $10.00 [ ] Notary Public Name Change - $10.00 COUNTY OF _______________________ To: Secretary of State of South Carolina Name on original application ___________________________________________________________ IF requesting a name change, enter new name here __________________________________________ Present Address______________________________________________________________________ City and Zip Code ___________________________ Last 4 Digits of Social Security # ___ ___ ___ ___ Date of Birth _________________________ EMAIL_________________________________________ (Voter Registration #) _____________________________ Date ___________________________________ _________________________________________________ Signature of Applicant Sworn to and subscribed before me this ___________day of ________________________20_____ *Please sign here exactly as you will sign when you notarize documents. ________________________________________________ Notary Public of South Carolina My Commission expires___________________ MAIL REQUEST FORM AND CORRECT FEE TO THE ABOVE ADDRESS American LegalNet, Inc. www.FormsWorkFlow.com