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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. Prexes
(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 identication 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 ofce boxes will be accepted. Kansas statutes require the notary certicate 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
address.
•
Daytime phone Enter the applicant’s daytime telephone number. (Required)
•
Secondary phone Enter the applicant’s secondary telephone number. (Optional)
•
Seal/stamp impression Afx 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 certicate 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 ofce supply stores.
kansas secretary of state
Notary Public
Appointment Form
Instructions
NO
The following form must be complete and
accompanied by the correct filing fee or the
document will not be accepted for filing.
Inst.
K.S.A. 53-103
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 certicate from the Kansas Secretary of State.
Please
Do Not
Staple
Continue to next page
B. Oath (Required before submitting) K.S.A. 53-102
•
Signature The applicant must sign the appointment form after reciting the oath in the presence of a legally
authorized notary public. The alternative afrmation in parentheses may be recited instead of the italicized
commencement and conclusion of oaths. K.S.A. 54-104.
•
State/County The notary completing the oath (notarizing the applicant’s signature) should complete the state and county
in which the notarization takes place. K.S.A. 53-508.
•
Date administered The notary public who is notarizing the appointment form must complete the date the oath was
administered. K.S.A. 53-508.
•
Notary’s commission The notary public who is notarizing the appointment form must enter the date his or her notary
commission expires. K.S.A. 53-508.
•
Notary’s signature/seal The notary public who is notarizing the appointment form must sign the document and afx his or her
notary seal in the space provided above his or her signature. K.S.A. 53-508.
C. Notary Surety Bond (Required before submitting) K.S.A. 53-102
•
Surety bond The law requires a notary public to be bonded in the sum of $7,500 for a four (4) year period automatically
coinciding with the appointment. The bond must be a commercial surety bond from an insurance company
licensed to do business in Kansas. The surety company must complete this section.
•
Surety name & address Enter the name and physical address of the commercial surety company.
•
Surety signature The signature should be completed by the Attorney-in-Fact from the insurance company and also the date
he/she signed the bond. An insurance company must afx a corporate seal or attach its Power of Attorney.
Additional Information: Please review the Kansas Notary Public Handbook for information regarding Kansas notaries.
For a change of name, home or mailing address, stamp, or cancelation of the commission bond, please le a form NC.
kansas secretary of state
Notary Public
Appointment Form
Instructions
NO
Inst.
K.S.A. 53-103
Rev. 9/17/19 tc
Please proceed to form.
Please
Do Not
Staple
1 / 2
K.S.A. 53-103
Rev. 9/17/19 tc
62-01
THIS SPACE FOR OFFICE USE ONLY.
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 certicate from the Kansas Secretary of State.
Please check one: o
New appointment
o
Reappointment
Expiration date of your most recent Kansas appointment:
Month Day Year
(Your current expiration date must be used until the date of expiration has passed.)
A. Personal Information
1. Applicant’s name (Must match name on the seal in Item 7.) Previous name (If your name has changed from the previous appointment.)
2. Residential street address (P.O. box is not acceptable.) 3. Mailing address (Optional)
Residential Street Address Street Address
City State Zip City State Zip
4. Daytime phone (Required) 5. Secondary phone (Optional) 6. This section must be completed.
• Are you at least 18 years of age?
o
Yes
o
No
• Are you a resident of Kansas or a resident of
a state bordering Kansas who regularly carries
on a business or profession in this state or is
regularly employed in this state?
o
Yes
o
No
7. Afx an impression of applicant’s seal/stamp
(Name on seal/stamp must match applicant’s name in Item 1.)
• Are you able to read and write the English
language?
o
Yes
o
No
• Have you ever been convicted of a felony or
of a lesser offense involving moral turpitude or
of a nature incompatible with the duties of a
notary public? A conviction after a plea of nolo
contendere is deemed to be a conviction.
o
Yes
o
No
• Have you ever had a revocation, suspension or
denial of a professional license for misconduct,
dishonesty or any cause substantially relating to
the duties or responsibilities of a notary public?
o
Yes
o
No
kansas secretary of state
Notary Public
Appointment Form
Memorial Hall, 1st Floor (785) 296-4564
120 S.W. 10th Avenue notary@ks.gov
Topeka, KS 66612-1594 https://sos.kansas.gov
NO
Please
Do Not
Staple
Continue to next page
Print
Reset
Please complete the form, print, sign and mail to the
Kansas Secretary of State with the filing fee. Selecting
'Print' will print the form and 'Reset' will clear the entire
form.
B. Oath
I do solemnly swear* (sincerely and truly declare and afrm), under penalty of perjury, that the answers to all questions on this application
are true and complete to the best of my knowledge, and that I am qualied to be appointed and commissioned as a Kansas notary public.
8. Applicant’s signature
(Seal)
9. State of County of
10. Signed and sworn (or afrmed) to before me on:
Month Day Year
11. My appointment expires: 12. Notary’s signature
Month Day Year
* You may say the phrase inside the parentheses instead of the italicized words.
C. Notary Surety Bond (The surety company must complete this section)
Know All Persons By These Presents: That we, the above-named applicant as principal and
13. Name and address of surety company
Street Address
City State Zip
as surety company, give bond payable to any individual who may be harmed as a result of a breach of duty by said applicant acting in his/
her ofcial capacity as notary public, in the amount of seven thousand ve hundred dollars ($7,500) as assurance for the due discharge
of the duties of his/her ofce of notary public and we do bind ourselves, and each of our heirs, executors and administrators, jointly and
severally. Applicant was, on the date of issuance of commission, bonded as a notary public in and for the state of Kansas, to hold ofce
for the term of four years in accordance with the laws of this state. Now, therefore, if said applicant shall faithfully discharge the duties of
the ofce of notary public, as prescribed by law, then this obligation shall be void. Further, we, the surety company, understand that we
are required by K.S.A. 53-120 to report to the secretary of state the outcome on any claim led on this bond.
14. Signature of Attorney-in-Fact
(Corporate Seal)**
Date
Month Day Year
** Attach corporate seal or submit with the Power of Attorney.
Please review to ensure completion.
2 / 2
K.S.A. 53-103
Rev. 9/17/19 tc
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Completed 28 October 2019

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