Notary Commission Application037 The data which you furnish on this form will be used by the Office of the Secretary of State and the Department of Commerce to assess your qualifications for a commission. The information on this form, including your name and designated address, is public pursuant to Minnesota Statutes, Chapter 13. A. Application (Mark the box that applies to you) New Appointment Reappointment Address Change Renewal Name Change Fee: $120 Fee: $120 (Commission has expired) Fee: $120 Can renew online at notary.sos.state.mn.us No Fee Can update online at notary.sos.state.mn.us 002No Fee 002(Attach documentation) B. Commission Number (Required for reappointment, renewal, address change and name change) Current Commission Number C. Applicant Information 227 List your name the way it appears on your driver222s license, tax returns and legal documents First Name Middle Name or Initial Last Name Residential Street Address (PO Box must include Rural Route or Street Address) City State ZIP Date of Birth (applicant must be 18 years old) mo/day/yr Telephone w/ area code Email County of Residence ( Non-residents must list a Minnesota County he or she will be filing in upon receiving their notary commission from the Office of the Secretary of State) 002 D. Business Name and Address 227 This information is optional and applies if notarization is a function of your job Business Name Address (Business location where the notary conducts business, PO Box must include rural route or street address) Telephone w / area code City State ZIP Choose the address you would like displayed alongside your name on the Office of the Minnesota Secretary of State website. Failure to indicate a preference will result in an incomplete application. Residential Business E. Former Residential Address (Required if filing an address change. PO Box must include rural route or street address) F. Former Name (Required if filing a name change. Must attach legal document showing name change, e.g. copy of marriage certificate, divorce decree, driver222s license, court order, etc.) American LegalNet, Inc. www.FormsWorkFlow.com NOTE: You do not need to answer YES below if the answer is due to an event(s) that occurred PRIOR to your last approved application to be a notary public and after having submitted the supporting documentation. However, if new issues leading to a YES response have occurred since then, you must file this Notary Application form, including YES answer(s) and provide the supporting documentation that is requested. If the answer to any question is YES, you must attach an explanation including the specific dates, charges, resolution, attach copies of legal documentation and complete the background check form. All items including these answered questions, Notary Application, Background Check Form and supporting documentation when applicable, must be mailed together to the Office of the Secretary of State. 1.Have you ever been the subject of any inquiry or investigation by any state agency?If yes, submit a written statement explaining the circumstances of incident and copies of Department letters or order which demonstrate the final resolution of the matter. YES NO 2.Have you or has any occupational license held by you been censured, suspended, revoked, canceled, terminated or otherwise been the subject to any type of administrative action in any state including Minnesota? If yes, submit: A. a written statement explaining in detail the type of license and the circumstances of each incident. B. a copy of the notice of hearing or other document that states the charges and allegations. C. a copy of the official document which demonstrates the resolution of the charges or any final judgment. YES NO 3.Have you ever been charged with, or convicted of, or been indicted for, or entered a plea to, any criminaloffense (felony, gross misdemeanor or misdemeanor), in any State or Federal Court? You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, DUI, DWI or driving without a license, reckless driving, or driving with a suspended or revoked license. You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court). If yes, submit: A. a written statement explaining in detail the circumstances of incident, copies of police report and charging documents. If no longer on file, submit a statement as such from the charging authority on their letterhead. B. copies of the sentencing and disposition documents. Register of Actions is not acceptable unless it contains an official court stamp confirming that it is the only document available. If currently on probation, attach letter from probation officer stating compliance with terms of probation. If not currently on probation, state you are not on probation. YES NO 4.Have you been a defendant in any lawsuit involving claims of fraud, misrepresentation, conversion,mismanagement of funds, breach of fiduciary duty or breach of contract? If yes, submit: A. a written statement explaining in detail the circumstances of incident. B. a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceeding. C. a copy of the official documents, which demonstrate the resolution of the charges or any final judgement. YES NO American LegalNet, Inc. www.FormsWorkFlow.com APPOINTMENT OF THE SECRETARY OF STATE AS AGENT FOR SERVICE OF PROCESS. KNOW ALL PEOPLE BY THESE PRESENT: That in compliance of the Laws of the State of Minnesota, I, the undersigned applicant, if a nonresident, do hereby appoint the Secretary of State of the State of Minnesota, his/her successor or successors, as my true and lawful agent upon whom may be served all legal process in any action or proceeding in which I may be a party arising out of or re-lating to the transactions of the commission, and do hereby expressly consent and agree that service upon such agent shall be as valid and binding as if due and personal process has been made upon me and that such appointment shall be irrevocable. I certify that the statements in this application and attachments are true and complete and that this document has not been altered or changed in any manner from the form adopted by the Office of the Secretary of State. OATH: I swear to uphold the duties of a Notary Public in the State of Minnesota. Signature of Notary Applicant Date American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS002 002 1.To obtain a Notary commission, submit this completed application with the application fee to the Office of the Secretary of State. 2.The notary commission fee is $120.00. The fee is non-refundable and must be paid by check or money order made payable to theOFFICE OF THE SECRETARY OF STATE Do not send cash through the mail. 3.Applicant must be at least 18 years of age. Applicant must be either a Minnesota resident, or a resident of a county in IA, ND, SD,or WI and list the Minnesota County he or she will be filing in upon receiving their commission. Non-resident notary applicants must designate the Secretary of State as their agent for service of process. 4.Upon receipt of your commission, you must register it with the county. Your resident county name and telephone number will belisted in the instructions portion of your commission certificate. Please contact the county for directions to the appropriate location to register your commission. Note: there is a $20.00 fee charged at the county level. 5.Upon receipt of your commission, you must purchase a notary stamp. When you notarize a document, your notary stamp mustmatch the name on your commission certificate however you may sign documents using your normal signature if different then what is listed on your commission certificate. 6.Notary commissions expire on January 31 of the fifth year following the year of issue. Applications for renewal may be submitted6 months prior to the expiration date of your current commission or a reappointment can be made any time after the expiration of your commission. Upon receipt of your new commission, re-register your commission with the county where you ar