A. Personal Information (required before submitting) K.S.A. 53-102
Filing fee Submit this form with the $25 ling fee for the notary appointment form.
Payment Please submit payment by check, money order, or credit card. Checks and money orders need to be
made payable to the Secretary of State. Forms received without the appropriate fee will not be accepted
for ling. Please do not send cash.
Visa, MasterCard, Discover, and American Express are accepted. To use a credit card, please provide
the following information:
Credit card number __________________________________________________________________
Billing zip code _____________________________ Expiration date _________________________
NOTICE: There is a $25 service fee for all returned checks.
Appointment Mark if this is a new appointment or if this is for reappointment.
Expiration date Enter the expiration date of the applicant’s last appointment if he or she is currently a Kansas notary
public or has ever been a Kansas notary public.
Applicant name The name in item 1 must match exactly to the name printed on the notary stamp in item 7. Prexes
(Doctor, Father, Mrs.) are not acceptable. To use initials for the rst name, you must submit a photo copy
of a government-issued ID that shows an initial as a rst name. We recommend that your name be listed
as it is listed on your state-issued driver’s license or identication card. K.S.A. 53-105.
Residential address Enter the street address of the residence of the applicant. This must be a physical street address – no
post ofce boxes will be accepted. Kansas statutes require the notary certicate be mailed to the notary’s
residential address upon appointment.
Mailing address This is an optional address that may be provided if mail cannot be received at the residential street
Daytime phone Enter the applicant’s daytime telephone number. (Required)
Secondary phone Enter the applicant’s secondary telephone number. (Optional)
Seal/stamp impression Afx an impression of the notary stamp that the applicant will be using. If the applicant chooses to use more
than one stamp, an impression of each must appear in the space provided. The applicant may either use
a “seal press” (impression seal) with the impression to be blackened, or a rubber stamp to be used with
permanent ink. The seal must include the applicant’s name and the words “Notary Public” and “State of
Kansas.” “My appointment expires __________ ” also may be included. Do not include the county within
the seal. Although you must obtain your seal or stamp before completing the appointment process, you will
not be authorized to notarize documents until you receive your certicate of appointment from the Secretary
of State. The name on the stamp must match the name entered on the appointment form in item 1.
K.S.A. 53-105. Stamps can be obtained from most ofce supply stores.
kansas secretary of state
The following form must be complete and
accompanied by the correct filing fee or the
document will not be accepted for filing.
Rev. 9/17/19 tc
IMPORTANT: This appointment form must be submitted by mail and include the $25 ling fee. If renewing
your notary appointment, please do not submit this form before 90 days prior to your expiration date. You
are not a notary until you receive your notary certicate from the Kansas Secretary of State.
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