Вы находитесь на странице: 1из 2

[

I
i
i
MINNESOTA
SECRETARY OF STATE
Retirement Systems of MN Building
60 Empire Drive, Suite 100
St. Paul, MN 55103
651-296-2803 (toll fee at 1-877-551-6767)
Press Option 3
Email: nota .sos state.mn.us
NOTARY COMMISSION
APPLICATION
(For Department Use Only)
48359300002
DATE PROCESSED
\ ~,
The data which you furnish on this form will be used by the Offce of the Secretary of State and the Deparment of Commerce to
assess your qualifictions for a commissio
n
. After issuance of the coMHission your name and designated address Is public
pursuant to Minfesot Sttutes, Chapter 13.
A. APPLICATION (Checkapp'cab|ebox)
REAPPOINTMENT
Fee:S120
(commission has expired)
D RENEWAL
Fee:S120
(can also b renewed online
at notary.sos.state.mn.us)
j ADDRESS CHANGE
No Fee
(can also upate online at
notary.sos.state.mn.us)
j NAME CHANGE
No Fee
(attach legal
documentation)
1,-^, B . OMMISSION-NUMBER (Required-for,reappointment, renewal;.acdresschange,and-name change),--.: '
.
I
CURRENT COMMISSION NUMBER
r
I
C. APPLICANT INFORMATION (list your name the way it appears on your driver's license, tax returs and legal documents.)
FIRST NAME MIDDLE NAME OR INITIAL LAST NAME
C\
` cv>|<\`~
RESIDEN AL STREET ADDRESS (PO Box must include Rural Route or Street Address)
/42 C\~o /e

` ''
CITY STATE
Pd.ck.


DATE OF BIRTH (A plicant ust be 18 years old) TELEPHONE NUMBER with area coe EMAIL ADDRESS
ZIP CODE
mo/day/yr:
(;Sl ) 260 I 'o 0" T' ' ~ " '

COUT OF RESIDENCE (Non-residents must list a Minnesota County he or she will be filing in upon reciving their notary commission from the
Ofice or the Secretary of State.)
\ ev
, "
0. BUSINESS NAME AND ADDRESStional -lies when notarization is a function otourjob)
BUSINESS NAME
0" \ (c\\(cbo
BUSINESS ADDRESS (Business location where the notary conducts business, PO Box musl include Rural Route or Street Address)
3oq |c '=
CITY
I
STATE
M
. 1 ZIPCODE

< 1'
TELEPONEMBER with area coe
>
qg
jC
Check address you want shown on pUblic lists: (Must check one and can check both. If none are checked, default is residential)

.
_
Re,
;
d

I
A
dd

e,.
.
,;
n
e
;
A
dd
<
e"
.

FORMER RESIDENTIAL STREET ADDRESS (PO Box must include Rural Route or Street Address)
FORMER NAME (Must attach legal document showing the name change; i.e. copy of marriage certificate, divorce decree, driver's license, court order,
etc.)

+


ALL applicants MUST answer questions 1-4.
.If the answer to any quoetion is YES, you must attach an oxplanation ncluding the specific dates,
charges, resolution, attach copies of legal documentation and complete the background check mm.
All items including these answered guestions, Nota! Aication1 Background Check Form and
suring documentation when aicable, must be mailed together to the Ofice of the Secretar of
State.
1. Have you ever been the subject of any inquiry or investigation with respect to a notar commission or by any
YES
J
division of the Minnesota Commerce Deparment? (If yes, attach written explanation and copies of Deparen|
D
letters or order.)
2. Have you or has any ocupational license held by you been censured, suspended, revoked, canceled,
YES NO
tenninated or been the subject to any type of administrative action in any state including Minnesota? (If yes,
D

a||achwritten explanation and copies or Department letters or order.)
3. Have you ever been charged with, or convicted of. or been indicted for, or entered a plea to, any criminal offense
(felony, gross misdemeanor or misdemeanor), in any 6|a|eor Federal Cour? [If yes, attch written
---&planation-and-opies-of-complalnt,sentencing-and-disposition-documents;.and.if.(Umntly.on--


probation, attach letter from probation officer stating compliance with terms of probation.) Note: This
does NOT include traffic violations such as DUI, DWI, si >eedin_, etc.
4. Have you been a defendant in any lawsuit involving daims of fraud, misrepresentation, conversion,
YES

mismanagement of funds, breach of fiduciary duty or breach of contract? (If yes, attach written explanation and
D
copies of court documents.)
.
APPOINTMENT OF THE SECRETARY OF STATE AS AGENT FOR SERVICE OF PROCESS. KNOW ALL PEOPLE BY THESE PRESENT:
That in compliance of the Laws of the State of Minnesota, I, the undersigned applicant, if a nonresident, do hereby appoint the Secretary of State of
the State of Minnesota, his/her successor or sucessors, as my true and lawul agent upon whom may be served all legal process in any action or
proceeding in which I may be a party arising out of or relating to the transactions of the commission, and do hereby expressly consent and agree that
service upon such agent shall be as vali and binding as if due and personal process has been made upon me and that such appointment shall be
irrevocable.
I ce!|qthat the sta|emea|s in this application and a||achec|sare tre and cmplete and that this document has not been altered or
changed in any manner from the form adopted by te Offic of the 6eoeta|yof State.
OATH: Sw0I O UQDOU D0 0U0S O NOf UDC D D0 0 O NDD0SO.

Signature of Notary Applicant Date

Вам также может понравиться