PAUL D. PATE Secretary of State State of Iowa Application for Appointment as Notary Public Read instructions before completing this application. Please type or print information clearly. 1. Applicant's Name (as it will appear on the commission): _____________________________________________________________________________________________________________ First Middle (Optional) Last 2. Applicant's Home Contact Information: ____________________________________________________________________________________________________________ House Number Street Name City State ZIP Code _____________________________________________________ Home Phone Number ______________________________________________________ Home Email Address Employer's Name City 3. Applicant's Employer Contact Information: ____________________________________________________________________ _____________________________________________________________________________________________________________ Building Number Street Name State ZIP Code ____________________________________________________ Applicant's Work Phone Number _______________________________________________________ Applicant's Work Email Address 4. Preferred Contact Method: Designate preferred contact method. If no designation is made, home contact information will be used. Home Contact Information Employer Contact Information If applicant has provided business contact information different from home contact information, applicant may opt to shield home contact information from display on the Secretary of State's Web site. Does applicant wish to exercise this option: Yes No 5. Qualifications: Does applicant meet all the qualifications as stated in Iowa Code section 9B.21 (2): Applicant is a resident of: Iowa or resident of __________, a state bordering Iowa. Yes No 6. Electronic records � Effective January 1, 2013: Will applicant be performing notarial acts with respect to electronic records: Yes No If "Yes", identify the tamper proof technology the applicant intends to use: _______________________________________________ 7. Bilingual Notary Registry: Does applicant wish to have name placed on a list of bilingual notaries: Yes No If "Yes", list the language(s) in which applicant is fluent: ___________________________________________________________ 8. Affirmation and Signature: By submitting this filing I hereby affirm that I will support the Constitution of the United States and the Constitution and laws of the state of Iowa, I will faithfully and impartially discharge the duties of notary public according to the best of my ability, and that I have read and understand the requirements of Iowa Code chapter 9B and administrative rules in 721-chapter 43, and that I may not notarize any documents until I have received my notary commission from the Secretary of State. _______________________________________________________________ _______________________________________ Date Applicant's Signature 9. Fee: $30.00. Make check payable to SECRETARY OF STATE. Applicants filing by paper may obtain a copy of Iowa Code chapter 9B at the following website: https://www.legis.iowa.gov/DOCS/ACO/IC/LINC/Chapter.9B.pdf Rev. 1-15 American LegalNet, Inc. www.FormsWorkFlow.com PAUL D. PATE Secretary of State State of Iowa Instructions for Application for Appointment as Notary Public Incomplete or incorrect applications will be returned. A notary commission for a resident is 3 years; nonresident is 1 year. If any information on this application changes during the duration of the commission, the Secretary of State must be notified within 30 days of the change. Records of Iowa notaries are public record. 1. Applicant's Name: Documents must be notarized using the name that appears on the commission (e.g. if a middle initial is provided on this form it must be included during notarizations). A stamp or seal must be used when notarizing documents. The name on the stamp or seal must be identical to the name that appears on the notary's commission. 2. Applicant's Home Contact Information: Provide complete home address, phone number, and email address. 3. Applicant's Employer Contact Information: Provide name of applicant's employer, employer's complete address, applicant's work phone number, and work email address. 4. Preferred Contact Method: Check box to indicate applicant's preferred contact method. If box is not checked, home address will be designated. If applicant has provided business contact information different from home contact information, applicant may opt to shield home contact information from display on the Secretary of State's Web site. Check box to indicate if applicant would like to exercise this option. 5. Qualifications: Check boxes to indicate whether applicant meets all the requirements as stated in Iowa Code section 9B.21(2) and administrative rules in 721-chapter 43, and whether applicant is a resident of Iowa or resident of a state bordering Iowa with place of work or business within the state of Iowa. If applicant is not a resident of Iowa, print the abbreviation for the bordering state in which the applicant resides. Applicants filing by paper may obtain a copy of Iowa Code chapter 9B at the following Web site: https://www.legis.iowa.gov/DOCS/ACO/IC/LINC/Chapter.9B.pdf 6. Electronic Records � Effective January 1, 2013: Check box to indicate whether applicant will be performing notarial acts with respect to electronic records. If "Yes", identify the tamper proof technology the applicant intends to use. 7. Bilingual Notary Registry: Check box to indicate whether applicant wishes to have name placed on a list of bilingual notaries. If "Yes", identify the languages in which applicant is fluent. This information is used by notaries and the public for referral of clients who do not speak English or have documents in languages other than English which require notarial services. 8. Affirmation and Signature: Applicant must affirm the statement by signing the completed application. 9. Fee: $30.00. Make check payable to SECRETARY OF STATE DURATION OF COMMISSION: For an Iowa resident, a notary commission is effective for 3 years from the date of commission. For a resident of a bordering state, a notary commission is effective for 1 year from the date of commission. CHANGES: If any information contained on this application changes during the term of your notary appointment, you are required to notify the Secretary of State within 30 days. NOTICE: Iowa notary public recor