COMPLETE, PRINT, SIGN IN FRONT OF NOTARY AND MAIL
APPOINTMENT OF AGENT FOR NOTARY SERVICE OF PROCESS
SECRETARY OF STATE
SFN 19369 (12-03)
Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500 Telephone 701-328-2901 Toll Free 800-352-0867 Ext 82901 Fax 701-328-1690
For reference, see North Dakota Century Code, Section 44-06-01. In compliance with the Federal Privacy Act of 1974, the disclosure of the social security number on this form is voluntary. They are not disclosed to the public. The numbers are used by the Secretary of State to maintain accurate notary files. Therefore, while voluntary disclosure is requested, failure to do so will not invalidate this appointment of agent for notary service of process.
Name of Applicant Residential address of Applicant E-Mail Address (Optional) Telephone # City Social Security # State Zip Code
The undersigned does hereby appoint the North Dakota Secretary of State as his true and lawful agent upon whom may be served all lawful process in any action or proceeding against the undersigned, a non-resident notary.
State of _____________________ County of ___________________
The foregoing instrument was acknowledged before me this _____ day of ____________________, 20 ____.
My Commission Expires__________________________________