MISSISSIPPI SECRETARY OF STATE POST OFFICE BOX 136 JACKSON, MISSISSIPPI 39205-0136 APPLICATION FOR NOTARY PUBLIC CHANGE OF ADDRESS This application must be typed or printed in ink. This form is designed to be completed and printed from your computer. You will not be able to save the form on your computer unless you have the appropriate software. Return completed Application, together with the $20.00 fee to the Secretary of State's Office. The undersigned Notary, hereby, notifies the Secretary of State of the following change of address and/or other information: ______________________________________________, (Type or print name exactly as it appears on your Commission) _________________, (Commission expiration date) _______________ (Notary ID Number) Please insert new address and/or other changes: Street Address: __________________________________________ City: _______________, Mississippi Zip: ________ Telephone Number: ___________________________ County of Residence: Optional mailing address: ____________________________________ City: _____________, Mississippi Zip: ________ Please include a business/employer address and telephone number as you would like it to appear in the Notary Directory. If you do not include this information, you will be listed in the Notary Directory at your mailing or residential address. Business Name: ______________________________ Job Title: _____________________ Telephone: ______________ Mailing address: ____________________________________ City: _________________ State: ______ Zip: __________ Street address: _____________________________________City: _________________ State: ______ Zip: __________ This the ________ day of _____________, 20_______. ___________________________________________ Signature of Notary American LegalNet, Inc. www.FormsWorkFlow.com SOS FORM NP 004 April, 2007 PAGE 1 of 1 Pages