PRINT, SIGN AND MAIL TO: COLORADO SECRETARY OF STATE 1700 Broadway, Suite 200 Denver, CO 80290 303-894-2200 www.sos.state.co.us Office Use Only NOTIFICATION OF INTENT TO NOTARIZE ELECTRONICALLY Last Name: First Name: Middle/Initial: Suffix: Residence Address 1: Address 2: City: Zip Code: E-mail Address: Commission Expiration Date: Attention: Before completing this notification, please be sure you have read and understand the Notaries Public Act (title 12, article 55 CRS) and the Department of State Rules Concerning Electronic Notarization (8 CCR 1505-11). I, ___________________________________________, intend to notarize electronically. I solemnly affirm as follows: • This Notification constitutes my application for approval by the Secretary of State to notarize electronically. • I will not perform any electronic notarization until and unless I have been issued a Certificate of Approval, in accord with Rule 2 of the Rules Concerning Electronic Notarization. • I have carefully read the Notaries Public Act and the Rules Concerning Electronic Notarization, and, if I am approved to notarize electronically, I will faithfully perform electronic notarizations in accord with that law and those rules. • As my electronic notary signature, I will use (CHOOSE ONE): The document authentication numbers issued to me by the Secretary of State, accompanied by my name, the words “NOTARY PUBLIC” “STATE OF COLORADO” and “my commission expires” followed by the expiration date of my commission; OR The electronic sound, symbol, or process I have adopted as my notary signature, discrete to me and retrievable from an electronic document in perceivable form, accompanied by the document authentication numbers issued to me by the Secretary of State, my name, and the words “NOTARY PUBLIC” “STATE OF COLORADO” and “my commission expires,” followed by the expiration date of my commission. I have attached to this Notification an example of my electronic notary signature, together with a description of the technology used for its creation and the name, address, telephone number, and web or e-mail address of the supplier or vendor of that technology. Signed and verified this______day of __________________, 20_____. ___________________________________________ Signature of notary or notary applicant, exactly as it appears on the application for notary commission Please allow 1-2 weeks for processing. Upon approval, your certificate and document authentication numbers will be sent to your e-mail address. American LegalNet, Inc. www.FormsWorkFlow.com