A.

OFFICE OF THE
SECRETARY OF STATE
180 State Ofc Bkg.
10Or Marin Luther King Jr. Blvd
St. Paul, MN 55155
(651) 29-2803or1-877-551-767
Email: Nota .sos state.mn.us .
NOTARY COMMISSION
APPLICATION
(For Deparent Use Only)
Th data which you furish on this form wll be used by the Offc of the Secretary of State and the Deparent of Commerc to
ass

ss your
_
qualifctlons to; a lins. Disclosure of X
?
ur social security numbr is voluntary. The Ofc or the Departent may use
social securinumbe for 1dent1ction purp
:
ses. Failure to prove imSSN wll not prevent your applicaton from being reviewed

d
.
granted if othe1se appropnate. Afer issuanc of the cmmission your name and designated address is public pursuant to
Minnesota Statutes, Chapter 13.
A. APPLICATION (Check applicable box)
l NE APPOINTMENT
Fee: $40
0 RE-APPOINTMENT
Fee:$40
0 ADDRESS CHANGE
(No fee)
0 NAME CHANGE (No fee)
Attach legal doumentton
B. APPLICANT INFORMATION (please type or print legibly)
FIR NAME MIDDLE NAME OR INITIAL
; v
RESIDENT STREE
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DDRESS (PO Box must incude Rural Route o Street Adress)
0
* \O.
LA$T NAME
c< v Re.
STATE ZIP CODE
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DATE OF BIRTH (Applicnl must be 18 years old)
mo/day/y
04 h .\ \ l
TELEPHONE NUMBER wth area code
( Gl1 ) : 2 s - OS 2
COUNT OF RESIDENCE (Non-residenls mus\ list t Minneot County tnt
brders te non-resident County of Residence)
C9Fv<[
CURENT COMMISSION NUMBER (required for reappointment or name cange or add1ss cange)
FORMER ADDRESS (address change)
FORMER NAME (Must attch legal document showing the name change; i.e. a marrage cerficate. divone dacree. copy of drivers liense. court Or. etc.)
PLL B||11CBD1S NM BDSWB1 qMBS11ODS J-4.
If :the answer to any question Is YES, you must attach an explanation Including the specifc dates,
charges, resolution, atach copies of legal documentation and complete the BCA form. All Items
should be malled together to the Office of the Secreta_ of State
1 . Have you ever been the subject of any inquir or investigation with respect to a notary commission or by any
YES

. division of the Minnesota Commerce Deparment? (If yes, attach written explanation and copies of Department
Q
letters or order.)
2. Have you or has any occupational license held by you been censured, suspended, revoked, canceled,
YES NO
terminated or been. the subject to any type of administrative action in any state including Minnesota? (If yes,
Q

attach written explanation and copies of Deparment letters or order.)
3. Have you ever been charged with, or convicted of, or been indicted for, or entered a plea to, any criminal ofense
YES

(felony, gross misdemeanor or misdemeanor). in any State or Federal Cour? (If yes. attach written explanation
D
and copies of complaint, sentencing and disposition documents, and if currently on probation, attach letter from
, probation officer stating compliance with terms of probation.) Note: This does NOT Include traffic vlolatlons
such as DUI DWI, speedin etc.
4. Have you been a defendant in any lawsuit involving claims of fraud, misrepresentation, conversion,
YES

mismanagement of funds, breach of fiduciar duty or breach of contrac? (If yes, attach written explanation and
Q
copies of court documents
.
)
Rev. 01105 Page 1of2
APPOINTMET OF THE SECRETARY OF STA !E AS AGENT FOR SERVICE OF PROCESS. KNOW ALL PEOPLE BY THESE PRESENT:
That In compliance of the L of the State of Minnesota, I, the undersigned applicant, if a nonresident, do hereby appoint the Scretary of Slate of
t Stte of Minnesota, his/her sucssor or successors. as my true and lawl agent upn wom may b served all regal procss In any acion or
proeed1in Wic I may b a party arising out of or relating to the transactions of the commission, and do hereby expressl cnsent and agree that
. sc upo such agent shall b as valid and binding as I due and personal proces has been made upon m and that such appointment shall be
Irrevocble.
I crf that the statement In this applicton and atcment ar t and Cmptte and tat this docment has not ben alered or
cane in any manner fom the f adopted by t Ofc of te Secretar of Stat.
swear to uphold the duties of a Notary Public in the State of Minnesota.
o
\ \ O
Date

4F . "" "` * .
N S TR UCTIO N S
J.
To obtain a Notary commission, submit tis completed application with the application le to the Office of the Secretar of State.
2. The notar commission fee Is $0.00. The fee is Mn-refundable and must be paid by check or money order made payable to the
OFFICE OF THE SECRETARY OF STATE Do not send cash through the mail.
3. Applicant must be at least 16 year of age. Applicant must b either a Minnesota resident, or a resident of a county In I ND, SD, or W
that shares a boundary with a Minnesota county. Non-resident notary applicants must designate the Secretar of State as their agent for
serice of process.
4. Upon receipt of your commission, you must register with the District Court Administrator's Ofic or the County Recorder of your
resident Minnesota county. The commission of a non-resident notar must be recorded in the Minnesota county that borders the county
In which the non-resident notary resides.
+
5. Upon receipt of your commission, you must purchase a notary stamp.
6: Notary commissions expire on January 31 of the fifth year following the year of issue. Applications for renewal may be submitted 60 days
prior to the expiration date of your current commission or a reappointment can be made any time after the expiration of your commission.
Upon receipt of your new commission, re-register your commission with the District Court Administrator's Ofice or the County Recorder of
the county for which you are commissioned, and purchase a new notar stamp.
7. Name Change Application: Please attach your former commissiein to this application. You must also attach a copy of a legal docment
showing the name change (for example, marriage crtificate, divorc decree, or other legal documentation). \pon recipt of your new
cmmission, re-register your commission with the District Court Aministrator's Offce or the County Recorder of the county for which you
are commissioned, and purchase a new not
.
ary stamp.
6. Address Changes: You must notify the Secretary of State of any address change within 30 days. If you have changed your home
address to a new county, re-register your commission with that county's District Court Administrator.
9. Minnesota Statutes. Chapters 357, 356. and 359 (which govern notaries and notarial acts) may be downloaded from lhe Minnesota
Legislalure website www. leg.state.mn.us or purchased through the Minnesota Bookstore (phone 651-297-3000).
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OFFICE OF THE
SECRETARY OF STATE
180 State Ofc Bldg.
100 Dr Martin Luter Kng Jr. Bl
St. Paul, MN 55155
(651) 296-2803 or 1-877-551-6767
Email: Notar.sos@state.ms
BCA FORM
Bureau of Criminal Apprehension
Criminal Background Check
llS BCA FORM MUST BE COMPLETED BY ALL NOTARY PUBLIC APPLICANTS. THE DEPARTMENT OF COMMERCE USES THIS
INFORMATION TO CONDUCT CRIMINAL HISTORY C HECKS.
TO: Bureau of Criminal Apprehension
RE: Request for Criminal Background Check
--"**Pte\SE PRINT**---- ....
PROVIDE COMPLETE LEGAL NAME OF APPLICANT
LST NAME FIRSTNAfE
S 0e < AV1_
MIODLENAME
QATE OF BIRTH (mo/day/y) SECURITY NUMBER (optional)
0'\l \ i \
TPE OF LICENSE FOR WHICH YOU ARE APPL YING
NO|a( COUUl88On
"
THE FOLLOWING CERTIFICATION AND AUTHORIZTION MUST BE SIGNED BY ALL APPLICANTS:
I, the undersigned, have made application to the Office of the Secretar of State for a regulated
notar commis.sion.
I cerif that I have provided complete and accurate answer to all questions on my application.
I ereby requesUauthorize the Bureau of Criminal Apprehension to conduct a background check of me
through their records for licensing or notar commission purposes.
of Applicant
NOTE TO BUREAU OF CRIMINAL APPREHENSION:
Please enclose completed background investigation information in a sealed envelope along with this form.
Deparment of Commerce
Market Assurance Division
85 7th Place East, Suite 600
St. Paul, Minnesota 55101
651-296-6319
A Equal Opportunity Employer