State of Missouri John R. Ashcroft, Secretary of State Commissions PO Box 784, Jefferson City, MO 65102 Toll-Free (866) 223-6535 or (573) 751-2783 Print or Type 1. Name Application for Amended Commission as a Notary Public Change of Employer County (Application fee $5) (This name must appear as it is signed in #7) (Non-Resident Notaries Only) Date of Birth (MM/DD/YYYY) 2. Home Address City 3. New Employer Address City State Zip Code 4. Daytime Phone Number State Zip Code 5. Missouri Commission Number 6. CHANGE IN EMPLOYER COUNTY (For Non-Resident Notaries ONLY) County, Missouri, to I hereby request the Secretary of State to issue an amended notary public commission changing my county of employment from Missouri, where I am presently employed, effective on the day of County . 7. Signature and Email Address of Applicant (This signature must appear as it is typed or written in #1) PAYMENT $5 Check or Money Order Enclosed (Payable to Director of Revenue) NAME AS IT APPEARS ON CREDIT CARD EXPIRATION DATE SIGNATURE *Credit Card: Master Card Visa *($1.25 convenience fee will apply) CARD NUMBER (16 Digits) Discover American Express Form Comm. 56 (01/2017 American LegalNet, Inc. www.FormsWorkFlow.com 1. Name - You should print or type your name as you want it to appear on your commission certificate. You are required by law to use your full last name, while initials may be used for first and middle names. 2. Residence Address - Please provide the address at which you reside. If your mail goes to a post office box, please include a street address after the PO Box number. Also give the city, state and zip code. 3. New Employer - Indicate new employer's name and address. Amended Application Instructions Employer County Change (Non-resident Notaries Only) Date of Birth - Please provide your birth date in numerals: month/day/year. This is to confirm that applicants are at least eighteen years of age. 4. Daytime Phone - You are requested to provide a phone number where we can reach you BETWEEN THE HOURS OF 8:00 a.m. and 5:00 p.m., should we need to verify information given on the application in order to prevent the delay of returning the form to you for verification. 5. Missouri Commission Number - Please provide your commission number if you were commissioned after August 28, 2004. 6. Change in Employer County Enter the name and address of your new employer. Also include the new county and the effective date of employment. Please include your $5 application fee. 7. Signature - Complete the form by adding your signature in the same name style you indicated in # 1 on the application. Please include your previous notary certificate. You will receive a new certificate with your new information. Instructions Form Comm. 56 (01/2017) American LegalNet, Inc. www.FormsWorkFlow.com