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 City Application for Amended Commission as a Notary Public Change of Name or Change of County (Application fee $5) 2. Home Address (New Name--This name must appear as it is signed in #8) Date of Birth (MM/DD/YYYY) Zip Code 3. County of Residence (St. Louis City Residents please specify City) 4. Daytime Phone Number 5. Commission Number State (Non-resident ­ Missouri Employer County) (Provide new county if changing county.) 6. CHANGE IN NAME I hereby request the Secretary of State to issue an amended notary public commission from the name style the (Name as it appears on current Commission) (for those receiving commissions after August 28, 2004) to 7. CHANGE OF COUNTY day of (Type new name here) . effective on I hereby request the Secretary of State to issue an amended notary public commission changing my county of residence from Missouri, where I am presently residing, effective on the County, Missouri, to day of County . 8. Signature and Email Address of Applicant (New Name--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 American LegalNet, Inc. www.FormsWorkFlow.com Form Comm. 54 (01/2017) -- Page 1 of 2 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. Amended Application Instructions 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. 3. County of Residence - Please indicate the county in which you legally reside and are registered to vote, even if you work in a different county. You are commissioned for the county in which you live, but you are able to notarize anywhere in the state of Missouri. *If you reside in St. Louis City, please put St. Louis City in the county blank. 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. Commission Number - Please provide your commission number if you were commissioned after August 28, 2004. 6. Change in Name 7. Change of County Indicate both the previous name and the new name style under which you wish to be commissioned as a notary public. Indicate the previous county within and for which you were commissioned as a notary public and the new Missouri county to which you wish to have your commission amended. Note that the effective date is the date when your legal residency and voter registration in the new county, your new name style or your new county of employment became official. Please include your $5 application fee. 8. 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. American LegalNet, Inc. www.FormsWorkFlow.com Instructions Form Comm. 54 (01/2017) -- Page 2 of 2