Free Request for Certificate of Authorization to Obtain a Seal - Oregon

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STATE OF OREGON Corporation Division ­ Notary 255 Capitol Street NE, Suite 151 Salem, OR 97310-1327 503-986-2593 FAX 503-986-2300 FilingInOregon.com/notary

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NOTARY PUBLIC REQUEST FOR CERTIFICATE OF AUTHORIZATION TO OBTAIN OFFICIAL SEAL
PLEASE TYPE OR PRINT LEGIBLY IN BLACK OR DARK BLUE INK. FILING THIS FORM WILL NOT EXTEND YOUR COMMISSION EXPIRATION DATE. IT WILL STILL EXPIRE ON THE ORIGINAL DATE.

Notary Commission No:

Commission Expiration:

Notary Commission Name:

Current Address where notary materials should be mailed

Current Business Name & Address:

Current Resident Street Address (If different from mailing address above):

Daytime Phone Number & Extension:

Home Phone Number:

Message Phone Number:

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Please sign before another notary public.

I,

, do

swear

affirm that the following statement is true,

to the best of my knowledge: My original Official Seal or Certificate of Authorization has been lost, damaged, or destroyed, and I need a new Certificate in order to obtain a new official seal. I do not possess the Certificate/Official Seal and do not know who possesses it or where it is located. (If you need a Certificate for any other reason, please call first.) My original Commission Certificate is lost, damaged, or destroyed and I need a new one to display. On, (date) , I request that the Secretary of State issue a new Certificate of Authorization to obtain an Official Seal and/or Commission Certificate. In the event I reacquire possession of my original lost or misplaced Official Seal Certificate of Authorization Commission Certificate, I will notify the Secretary of State within 10 days.

X
Applicant Signature

State of

County of

Subscribed and

sworn

affirmed before me

By (Printed Name of Applicant)

this
(day)

day of
(month) (year)

X
Notary Public ­ Oregon (Signature)
506 (Rev. 10/08)