Submit this form and fee See fees listed below STATE OF OREGON Corporation Division – Notary 255 Capitol Street NE, Suite 151 Salem, OR 97310-1327 503-986-2593 FAX 503-986-2300 FilingInOregon.com/notary This Space For Office Use Only This Space For Office Use Only NOTARY PUBLIC NAME CHANGE PLEASE TYPE OR PRINT LEGIBLY IN BLACK OR DARK BLUE INK. ALL SECTIONS MUST BE COMPLETED. FILING THIS NAME CHANGE DOES NOT CHANGE YOUR COMMISSION EXPIRATION DATE Choose one: Please reissue my Commission in my new legal name, $5.00 fee required. I wish to continue using the name under which I was originally commissioned. This is an official name change notification only. No fee required. Notary Commission No: Commission Expiration: Notary Commission Name: New legal name: Commission name to be changed to: Reason for change: Print legal name as it appears on your official identification. Current Address where notary materials should be mailed Current Business Name & Address: Current Resident Street Address (If different from mailing address above): Daytime Phone Number & Extension: Home Phone Number: ( ( ) Applicant’s Legal Signature ) Effective date of change If you have requested that your commission name be changed, you will be issued an updated Commission and a Certificate of Authorization to obtain an Official Seal under that new name. The completed certificate must be returned to the Secretary of State within 10 days after receipt of your new official seal from the vendor. 503 (Rev. 10/08) American LegalNet, Inc. www.FormsWorkflow.com