*250202* *250202* BARBARA K. CEGAVSKE Secretary of State 101 North Carson Street, Suite 3 Carson City, Nevada 89701-3714 (775) 684-5708 Website: www.nvsos.gov Request for Amended Certificate of Appointment as a Notary Public ABOVE SPACE IS FOR OFFICE USE ONLY 1. Name of Notary as currently on file: 2. Notary Number: 4. Date of Birth: (mm/dd/yyyy) 3. Appointment Expiration Date: 5. Mother's Maiden Name: AMENDED CERTIFICATE REQUEST Name Change Mailing Address Change County Change - New County: Lost/Stolen Notary Stamp (Check all that apply) Filing Fee $10.00 Signature Change Place of Employment Change Duplicate Certificate Requested (attach copy of police report) (Include Area Code) Daytime Telephone Change: Work Home Cell Reinstatement of Appointment pursuant to NRS 240.033 Subsection 5 6. Legal Name of Applicant: (attach filing notice issued by county clerk) First Middle Last Suffix 7. Mailing Address in Nevada: Nevada Street Address or P.O. Box City Zip Code 8. Employer Information (Include Business Name: Telephone: Area Code) Street Address or P.O. Box City Zip Code The signature you use on this amendment form will become the only signature on file with the notary division of the Nevada Secretary of State's office used for verification when requested to authenticate any future notary acts. You must use your legal last name and your original signature. Use this signature on all notarial acts. I enclose the payment in the amount of $10.00 payable to the Secretary of State. I declare under penalty of perjury that information provided on this form is true and correct and acknowledge that pursuant to NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of State. X Applicant Signature Print name exactly as signed: Nevada Secretary of State Notary Amendment Revised : 1-5-15 American LegalNet, Inc. www.FormsWorkFlow.com