NOTARY PUBLIC EXAMINATION REGISTRATION Instructions: Complete this form in its entirety and send it along with the Application to Qualify to the Secretary of State’s office. The Examination Registration fee is $75 and the Application to Qualify fee is $25. Both must be filed with the Secretary of State’s office no later than 45 days prior to the date of the examination. Forms can be filed via mail, fax or email. The Credit Card Cover Sheet must accompany fax or email filings. Make checks payable to Secretary of State. This registration and fee is non-refundable and non-transferable. The information on this form and the disposition of the examination is public record (except for your social security #). Applicant’s Parish of Residence: Applicant’s Name: Applicant’s Mailing Address: zip: Applicant’s Phone Numbers: daytime: ( ) home: ( ) Applicant’s Social Security #: (last 4 digits only) DOB Email Address Examination Date: I understand that this registration and fee is non-transferable and non-refundable. Applicant’s Signature (required) ________________________________________________ Applicant’s Notary I.D. # (if applicable) __________________________________________ (Commissioned notaries do not have to file an Application to Qualify) (Check all that apply): Examination fee of $75.00:  check  money order  cashier’s check  credit card (cover sheet required) Application fee of $25.00: check  money order  cashier’s check  credit card (cover sheet required) Date Approved by Secretary of State: Mail to: Secretary of State  Notary Division  P.O. Box 94125  Baton Rouge, LA 70804 Physical Address: 8585 Archives Avenue  Baton Rouge, LA  70809 Email: notaries@sos.la.gov  Fax: 225.932.5359 Notary Exam Registration (updated 1/12) Prepared and Furnished by the Secretary of State American LegalNet, Inc. www.FormsWorkFlow.com