Free APP.P65 - Iowa

MICHAEL A. MAURO Secretary of State State of Iowa
1.
Name

Application for Appointment as Notary Public

READ the instructions on the back before completing this Application. TYPE or PRINT CLEARLY.

NOTE: Notarize all documents with the name exactly as provided above. (For example, if you choose to provide your middle initial above, always include it when you notarize.)

2.
Complete Home Mailing Address City, State, ZIP Home Phone Number

3.
Complete Employer Name Complete Employer Address

City, State, ZIP

Work Phone Number

4. Check the box to indicate which address you wish to designate for mailing purposes.
(If no address specified, home address will be designated.) Home Business If you have provided business contact information different from your home information, you may opt to shield your home address, phone number and e-mail from display on the Secretary of State's website. Would you like to exercise this option? Yes No

5.

E-Mail Address:

(optional)

6.

Date of Birth: ______/______/______. I am:
(check one)

(home) ________________________________

A resident of Iowa.
(work) ________________________________

A resident of _______________________, a state bordering Iowa, with work or business in Iowa.

7. Have you ever had your Notary Commission revoked or suspended or has any other discipline been imposed
upon you as a Notary in Iowa or any other state? __ Yes __ No If "Yes", please identify the state(s), the date(s) of the action(s) and the reason(s) for the action(s). ______________________________________________________________________________________ ______________________________________________________________________________________

8.

Have you been adjudged mentally incompetent or convicted of a felony? If yes, have you received a restoration of rights? ___ Yes ___ No

___ Yes

___ No

9. Do you wish to have your name placed on a list of bilingual notaries?

__ Yes __ No

List language(s) in which you are fluent:________________________________________________

10. Include your filing fee of $30.00.

Make check payable to SECRETARY OF STATE.

I certify under penalty of perjury and pursuant to the laws of the state of Iowa that the preceding is true and correct. I understand that I may not notarize any documents until I have received my notary commission from the Secretary of State.

11. ______________________________________
Signature

______________________
D a te rev 01/07

MICHAEL A. MAURO Secretary of State State of Iowa

Instructions for Notary Public Application

Incomplete or incorrect applications will be returned. Applications require approximately 4 to 14 days to process.

1.

NAME: Type or print your name. Remember, you must notarize all documents exactly as your name appears here. Effective January 1, 2002 you must use a stamp or seal when notarizing documents and your name on the stamp/seal must be the same as on your commission certificate. If you change your name during your Commission, you must notify the Secretary of State. ADDRESS: Type or print your complete home mailing address including city, state, ZIP and home phone. If your home address changes during your commission, you must notify the Secretary of State. BUSINESS ADDRESS: Type or print your complete business address including city, state, ZIP and business phone. If you change employers, you must notify the Secretary of State. MAILING ADDRESS DESIGNATION: Check the box to indicate which address you wish to designate for mailing purposes. If no address specified, home address will be designated. PRIVACY OPTION: If you have provided business contact information different from your home information, check the box to indicate whether you want to shield your home address information from display on the Secretary of State's website.

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E-MAIL ADDRESS: (Optional) If you have an E-mail address, provide it if you would like to receive information and announcements for Notaries. AGE and RESIDENCY: Iowa notaries must be at least 18 and a resident of Iowa or a resident of a state bordering Iowa with their place of work or business in Iowa. Provide your date of birth and check the box for your residency status. If not an Iowa resident, print the name of the bordering state in which you reside. REVOCATION: Indicate whether you have ever had your Notary Commission revoked or suspended and whether any disciplinary action has been taken against you in Iowa or any other state. If the answer is "Yes," provide a brief explanation including the state(s), why the action(s) was/were taken and the date(s) the action(s) was/were taken. VOTER REGISTRATION STATUS: Indicate whether you are currently disqualified from voting either because you have been convicted of a felony or adjudged mentally incompetent to vote. BILINGUAL NOTARY REGISTRY: Indicate if you wish to have your name placed on a list of bilingual notaries that would be made available to notaries and the public for referral of clients who do not speak English or have documents in languages other than English that require notarial services. Please list those language(s) in which you are fluent and would accept referrals.

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10. The filing fee is $30.00. Make check payable to SECRETARY OF STATE. 11. SIGNATURE: Sign and date your application.
DURATION OF COMMISSIONS: If the notary is an Iowa resident, a Notary Commission is effective for 3 years from the date of commission. If the notary is a nonresident, the commission is effective for 1 year from the date of commission. NOTICE: Records of Iowa Notaries are stored on microfilm and in computer databases. These records are available to the public. CHANGES: If information on this application changes during the duration of your notary appointment, you must notify this office. SECRETARY OF STATE Notary Public Clerk Lucas Building, 1st Floor Des Moines, Iowa 50319 Phone: (515) 281-5204 FAX: (515) 242-5953 Website: www.sos.state.ia.us