Secretary of State State of Iowa PAUL D. PATE Notary Public Change/Amendment to Application PRINT THE FOLLOWING INFORMATION AS IT APPEARS IN OUR SYSTEM: Name (as(as it appears on your certificate) __________________________________________________________________________________________ Name it appears on your certificate) __________________________________________________________________________________________ Address __________________________________________________ City __________________________State _____________Zip Code__________ Address __________________________________________________ City __________________________State _____________Zip Code__________ Date Commission Expires: ____________________________________________ Commission No: __________________________________________ Date Commission Expires: ____________________________________________ Commission No: __________________________________________ 1. CHANGE OF NAME (if applicable) I hereby request the Secretary of State amend my notary commission by changing my name on to: New Name (Print) ________________________________________________________________________ Date effective _____________________ I understand and agree that by notifying the Secretary of State of my name change I will use my new name when notarizing documents beginning on the effective date shown above through the end of my term. 2. APPLICANT'S HOME CONTACT INFORMATION (must complete) Address __________________________________________________ City __________________________State _____________Zip Code__________ Home Phone__________________________________________ Home Email Address___________________________________________________ 3. APPLICANT'S EMPLOYER CONTACT INFORMATION (must complete) Employer name________________________________________________________________________________________________________________ Employer Address__________________________________________ City __________________________ 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 employer contact information different from the home contact information, applicant may opt to shield the home contact information from display on the Secretary of State's website. Does applicant wish to exercise this option: Yes No 5. Qualifications: Does applicant meet all the qualifications as stated in Iowa Code 9B.21 (2): Applicant is a resident of: Iowa or resident of __________, a state bordering Iowa. Yes No Yes No 6. Electronic records � Effective January 1, 2013: Will applicant 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: 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. Applicant's Signature__________________________________________________ Date__________________________________________________ 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 Deliver completed application to: SECRETARY OF STATE Notary Public Division Lucas Building, 1st Floor Des Moines, IA 50319 Rev. 1-15 Phone: (515) 281-5204 Fax: (515) 242-5953 Website: sos.iowa.gov American LegalNet, Inc. www.FormsWorkFlow.com