(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 provision of KRS 423.110(6), the undersigned applies to the Office of the Secretary of State to be appointed by the Governor of Kentucky to the Office of Notary Public-Special Commission. 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. 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 of the county of residence of the applicant or in the couprincipal 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 Pu blic - Special Commission Application for Appointment ( Limited Liability Company or Limited Partnership) American LegalNet, Inc. www.FormsWorkFlow.com (12/17) SPECIAL COMMISSION NOTARY PUBLIC APPLICATION FOR APPOINTMENT INSTRUCTIONS BY LINE Line 1 Print or type name as it is to appear on the Certificate of Appointment, it must match your signature. Line 2 Date of birth including year. Line 3 Daytime phone number. Line 4 Home address where your Oath of Office & Certificate of Appointment will be mailed. Line 5 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 Commission 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. Signature of applicant the application is not complete until signed and matches name listed on line 1. Please mail application along with the fee of $10 to: Notary Commissions PO Box 821 Frankfort, Kentucky 40602-0821 You are applying for appointment to the office of Notary Public - Special Commission. A Notary Public - Special Commission is a resident or nonresident of Kentucky, who is appointed by the Governor of Kentucky to perform notarial acts in or outside this state covering writings prepared for recordation in this state. KRS 423.110(6). Notaries receiving the appointment to this office are specifically limited to the acts described in this paragraph. After the application has been filed and approved by the Secretary of State, you will receive a Notice of Appointment. Attached to the Notice of Appointment will be a printed Oath of Office. Pursuant to KRS 62.010, you must take the Oath of Office within thirty (30) days after you receive your Notice of Appointment. After the oath has been administered, the written Oath of Office must be returned to the Secretary of State within thirty (30) days from the date of your Notice of Appointment letter. Upon receipt by the Secretary of State of the Oath of Office, the Governor, through the Secretary of State, will issue to the applicant the Commission to Office. Failure to return the Oath of Office 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