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 Change of Employer Resident Notaries Non-Resident Notaries (Same County of Employment) (No fee) 2. Home Address City (This name must appear as it is signed in #9) Date of Birth (MM/DD/YYYY) 3. Previous Employer Previous Address City State Zip Code 4. New Employer Address City State Zip Code 5. County of Residence (St. Louis City Residents please specify City) 6. County of Employment (Non-Resident) 7. Daytime Phone Number 8. Commission Number (Resident) State Zip Code 9. Signature and Email Address of Applicant (This signature must appear as it is typed or written in #1) American LegalNet, Inc. www.FormsWorkFlow.com Form Comm. 58 (01/2017) -- Page 1 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 post office box number. Also give the city, state and zip code. 4. New Employer ­ Provide name and address of new employer. 3. Old Employer ­ Provide name and address of previous employer. Application for Change of Employer Resident Notaries Non-Resident Notaries (same county of employment) 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. 6. Non-Resident Notaries - Please indicate the county in which you are employed. 5. 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. 7. 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. 9. Signature - Complete the form by adding your signature in the same name style you indicated in # 1 on the application. The Secretary of State's Office can only accept original signatures - photocopied signatures will be rejected. 8. Commission Number - Please provide your commission number if you were commissioned after August 28, 2004. American LegalNet, Inc. www.FormsWorkFlow.com Instructions Form Comm. 58 (01/2017)