Free change.p65 - Iowa

MICHAEL A. MAURO Secretary of State State of Iowa

Notary Public Change/Amendment to Application

PRINT THE FOLLOWING INFORMATION AS IT APPEARS IN OUR SYSTEM:

Name (as it appears on your certificate) __________________________________________________________________________ Address _____________________________________________________________________________________________
Address City State Zip

Date Commission Expires: _____________________ Commission No: (found on your certificate)

____________________________

SECTION 1, COMPLETE ONLY IF IT APPLIES. SECTIONS 2 - 4 MUST BE COMPLETED SO THE INFORMATION CAN BE CHANGED/VERIFIED ON OUR RECORDS.

1. CHANGE OF NAME (if applicable) I hereby request that the Secretary of State amend my notary commission by changing my name on my notary commission to: _________________________________________________________ effective _____________________________
New Name (print) Date

I understand and agree that by notifying the Secretary of State of my name change I will use my new name when notarizing documents beginning on the effective date shown above through the end of my term. 2. HOME ADDRESS and PHONE (must complete)
The Secretary of State must have this information to change/verify it on the Notary's Commission.

______________________________________________________________________________________________
Address (including P.O. Box if applicable) City State ZIP

_____________________________________ ______________________________________________________
Home Phone Home E-mail Address

3. EMPLOYER NAME, ADDRESS and PHONE (must complete)
The Secretary of State must have this information to change/verify it on the Notary's Commission.

______________________________________________________
Employer Name

____________________________________
Employer Phone

______________________________________________________________________________________________
Address (including P.O. Box if applicable) City State ZIP

______________________________________________________________________________________________
Work E-mail Address

4. ADDRESS DESIGNATION (must complete) 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 I understand that I must be a resident of Iowa or a resident of a state bordering Iowa and work in Iowa to qualify as an Iowa notary. Signature ______________________________________________________ Date _______________________

SECRETARY OF STATE Notary Public Clerk Lucas Building, 1st Floor, Des Moines, IA 50319 Phone: (515) 281-5204 FAX: (515) 242-5953 or (515) 281-7142
rev 01/07

Website: www.sos.state.ia.us