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OFFICE OF E (For Department Use Only

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Empire Dr. Suite 100
St. Paul, MN 55103
(651) 296-2603
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Notary.sos@state.mn.us
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The data which you furish on this form will be used by the Offce of the Secretary of State and the Department of Commerce t o
assess your qualifications for a license. Disclosure of your social security number i s voluntary. The Offce or the Deparment may use
social security numbrs for identification purposes. Failure to provide the SSN will not prevent your application from being reviewed
and granted if otherwise appropriate. After issuance of the commission your name and designated address is public pursuant lo
Minnesota Statutes, Chapter 13.
P. PLP1lLN(Check applicable box)
NEW APPOINTMENT
Fee:$40
0 RE-APPOINTMENT
Fee: $40
0 ADDRESS CHANGE
(No ke)
0 NAME CHANGE (Nofee)
Ata lenl docmenlation
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FIRST NAME 1 MIDDLE ,E OR INITIAL
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LAST NAME
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RESIDENT STREET ADDRESS (PO Box must Incude Rural Route or Street Address)
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CITY
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ZIPCODE
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DATE OF BIRTH (Appliant mze 16 years old)
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TELEPHONE NUMBER wth ar0ae l EMAIL ADDRESS
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COUNTOF RESIDENCE (Non-esldent must list t Minnesota County tat l SOCIAL SECURITY NUMBER {optional)
borders to non-rosienl County o Residenc}
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CURRENT COMMISSION NUMBER (required for reappointment or name change or address change)
FORMER ADDRESS (4address change)
FORMER NAME (Must oltach legal doument showing the name change; i.e. a mamae certe, divorce decree. copy of drrvers license. court Or. etc.)
ALL applicants must answer questions 1-4.
If the answer to any question Is X, you must attach an explanation Including the specific dates,
charges, resolution, and attach copies of legal documentation.
1.
2.
3.
4.
Have you ever been the subject of any inquiry or investigation with respect to a notar commission or by any
division of the Minnesota Commerce Department? (If yes. attach written explanation and copies of Department
letters or order.)
Have you or has any occupational license held by you been censured, suspended, revoked, canceled,
terminated or been the subject to any type of administrative action in any state including Minnesota? (If yes,
attach written explanation and copies of Department letters or order.)
Have you ever been charge with. or convicted of, or bee n indicted for. or entered a plea to, any criminal offense
(felony, gross misdemeanor or misdemeanor). in any State or Federal Court? (If yes, attach written explanation
and copies of complaint, sentencing and disposition documents, and if currently on probation, attach letter from
probation off complianc with terms of probation.) Note: 1hl8do08 NOT |6lud8m0v|olatlon8
8uca8 WI 0dl 0tc.
Have you been fendant in any lawsuit involving claims of fraud, misrepresentation. conversion,
mismanagement of funds, breach of fduciary duty or breach of contract? (If yes, attach written explanation and
copies of court documents.)
Rev. 9/05 Page 1of2
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