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 Commission as a Notary Public (Application fee $25) 2. Home Address (This name must appear as it is signed in #18) Date of Birth (MM/DD/YYYY) Zip Code 3. County of Residence (St. Louis City Residents, please specify St. Louis City) 4. Daytime Phone Number Street City 5. Employer/Name of Business State State E-mail address 6. Missouri Commission Number (if reapplying) 8. Previous Name (if your name has changed) Zip Code 7. Previous Commission Expiration Date (if any) Check YES or NO for the following questions: 9. Are you at least eighteen years of age? 10. Are you a registered voter of the county for which you have applied to be commissioned or a permanent resident alien? (Section 245, Immigration and Nationality Act requires that you, attach a copy of your green card) 11. Do you live in the county within and for which you have requested to be commissioned? 12. Are you able to read and write the English language? 13. Have you been refused a commission as a notary public or had a commission revoked? (If yes, attach a separate letter indicating reason and date.) 14. Have you ever been convicted of or pled guilty or nolo contendere to any felony? (If yes, attach a list and supporting documentation of such convictions or pleas of guilt or nolo contendere.) 15. Have you ever been convicted of or pled guilty or nolo contendere to any misdemeanor incompatible with the duties of a notary public? (If yes, attach a list and supporting documentation of such convictions or pleas of guilt or nolo contendere.) 16. Have you read the Missouri Notary Public Handbook and know the laws and duties of a Notary Public? 17. Have you completed a state-approved notary training? (Attach your certificate of completion or your completed written notary training form.) 18. NOTARIAL OATH STATE OF MISSOURI YES YES YES YES YES YES NO NO NO NO NO NO YES NO YES YES NO NO X Signature of Applicant (Signature MUST appear as it is typed or written in #1 above) American LegalNet, Inc. www.FormsWorkFlow.com I, the person named above, do swear or affirm, under penalty of perjury, that the answers to all questions on this application are true and complete to the best of my knowledge and that I am qualified to be appointed and commissioned as a Missouri notary public. Form Comm. 51 (01/2017) -- Page 1 of 2 PAYMENT $25 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 1. Name - 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. Home 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. Date of Birth - Please provide your birth date in numerals: month/day/year. This is to confirm that applicants are at least 18 years of age. Application Instructions 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 Number - 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. 5. Employer / Name of Business - Your employer's name is requested should we need to contact you during working hours. If unemployed, please enter "N/A" or enter "Self-employed" if you own your own business. 7. Previous Commission Expiration Date - Please provide if reapplying. E-mail Address - Please provide your e-mail address. 6. Missouri Commission Number - If reapplying, please provide your Missouri commission number. 9-17. Yes or No - Please READ CAREFULLY AND ANSWER CORRECTLY the nine questions listed on this portion of the application. 18. Notorial Oath - Complete the form by signing your name in the same name style you indicated in #1 on the application affirming that the information provided is true and complete. 8. Previous Name - If your name has changed since your last commission, please provide your previous name. $25 application fee as required under Sections 486.225.2 and 28.160.3 RSMo Certificate of state approved notary training or completed written notary training form REQUIRED ENCLOSURES: FORM MUST BE SIGNED UNDER OATH ON FRONT PAGE American LegalNet, Inc. www.FormsWorkFlow.com Form Comm. 51 (01/2017) -- Page 2 of 2