MISSISSIPPI SECRETARY OF STATE POST OFFICE BOX 136 JACKSON, MISSISSIPPI 39205-0136 APPLICATION FOR NOTARY PUBLIC CHANGE OF NAME 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 name: _____________________________________________, (Type or print name exactly as it appears on your Commission) ___________________, (Commission expiration date) _____________ (Notary ID Number) Please insert new name:___________________________________________________________ (Type or print name exactly as you want it to appears on your replacement commission) The name change is as result of the following: Check one: Marriage Divorce Court Order Other Copies of appropriate documentation should be attached. If you are also changing your address you may include any changes below: 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 005 April, 2007 PAGE 1 of 1 Pages