(12/17) COMMONWEALTH OF KENTUCKY FEE $10.00 ALISON LUNDERGAN GRIMES, SECRETARY OF STATE Division of Corporations Notary Commissions PO Box 821 Frankfort, KY 40602 (502) 564-3490 www.sos.ky.gov PURSUANT to the provisions of KRS 423.110, the undersigned applies to the Secretary of State of the Commonwealth of Kentucky to be appointed to the Office of Notary Public for the State at Large. For this purpose the undersigned applicant makes the following statements: 1. Name of applicant: (Please print or type name as it is to appear on your commission certificate.) 2. Date of birth: 3. Daytime phone number: (month-day-year) (Include area code) 4. Home address of applicant where notification will be mailed: 5. County of Commission (County specified for 5a or 5b a. Kentucky County of Residence: or b. ce of employment is located 6. Application is being made for: new appointment reappointment (my commission expires on: Month Day Year ) (Please do not send your application for reappointment earlier than four (4) weeks before your current commission is to expire.) 7. Check the box if you wish to have your mailing address published on the notary website. CERTIFICATE OF APPROVAL (Must be completed by a county official BEFORE mailing to the Secretary of State Notary Commissions) The undersigned, an official authorized by statute to approve this application, states that the applicant herein is over eighteen (18) years of age, if a Kentucky resident, is a resident of or principally employed in the above-named county, or if not a Kentucky resident, but is employed in Kentucky, is principally employed in the above named county, and is capable of discharging the duties imposed by law upon the Office of Notary Public of the Commonwealth of Kentucky. NOW, THEREFORE, by virtue of the foregoing statements I have made and the authority granted to me by statute, my approval to the foregoing application is hereby granted. Name of Official: Please Print or Type Signature of Official: Please Print or Type Please Print or Type Please Note: The Certificate of Approval must be signed by one of the following officials: Circuit Judge, Circuit Clerk, County Judge/Executive, County Clerk, Justice of the Peace (Magistrate) or Member of the General Assembly oprincipal place of employment is located. (Official signature must match county listed on line 5.) Email Address (to receive future notary reminders): Signature of Applicant: Notary Public State at Large Application for Appointment and Reappointment ( Limited Liability Company or Limited Partnership) American LegalNet, Inc. www.FormsWorkFlow.com (12/17) NOTARY APPLICATION FOR NEW APPOINTMENT OR REAPPOINTMENT INSTRUCTIONS BY LINE Line 1 Print or type name as it is to appear on the Certificate of Appointment, it must match your signature & bond Line 2 Date of birth including year Line 3 Daytime phone number Line 4 Home address where your written notice of appointment will be mailed, check box to add address to the notary website Line 5 County of Commission - If a Kentucky resident, this is the county where the applicant resides OR is principally employed. For an applicant who is not a Kentucky resident, but is employed in Kentucky, this is the county in which he or she is principally employed. (The county on this line should match the county of the official signature at the bottom Line 6 Check new appointment or reappointment if reappointment, list current expiration date. If previously a notary public and your commission has expired, please check new appointment. Please do not send reappointments in earlier than four (4) weeks before your current notary will expire. Line 7 Check this box if you would like your address to be published on the notary website. Certificate of Approval must be signed by one of the listed officials BEFORE mailing to Notary Commissions the county of the official signature should match the county listed on line 5 Print or type email address to receive future notary reminders such as renewal notices & notice to process bond Signature of applicant the application is not complete until signed and matches name listed on line 1 Mail completed application along with the fee of $10 (payable to the Kentucky State Treasurer) to: Notary Commissions PO Box 821 Frankfort, KY 40602-0821 After the application has been processed by the Secretary of State, your Certificate of Appointment will be sent to the county clerk in the county of commission as designated in line 5. At the same time the Secretary of State sends the Certificate of Appointment to the county clerk, a written notice will be sent to the applicant stating the Certificate of Appointment can be obtained from You will have thirty (30) days to to obtain your Certificate of Appointment and (1) Post Bond; (2) Take the Oath of Office; (3) File and record your commission in the office of the county clerk. For specific information regarding the bonding and oath process, you should make direct contact with your county clerk. Failure to post bond and take the oath within thirty (30) days will cause your commission to become void. This will necessitate the submission of a new application and fee to become a commissioned notary. American LegalNet, Inc. www.FormsWorkFlow.com