Fillable Notary Commission Application (Minnesota Department of Revenue)

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Notary Commission Application (Minnesota Department of Revenue)

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Notary Commission Application
The data which you furnish on this form will be used by the Office of the Secretary of State and the Department of Commerce to
assess your qualifications for a commission. The information on this form, including your name and designated address, is public
pursuant to Minnesota Statutes, Chapter 13.
A. Application (Mark the box that applies to you)
New Appointment
Reappointment Address Change
Renewal
Name Change
Fee: $120 Fee: $120
(Commission has expired)
Fee: $120
Can renew online at
notary.sos.state.mn.us
No Fee
Can update online at
notary.sos.state.mn.us
No Fee
(Attach documentation)
B. Commission Number (Required for reappointment, renewal, address change and name change)
Current Commission Number
C. Applicant Information — List your name the way it appears on your driver’s license, tax returns and legal documents
First Name Middle Name or Initial Last Name
Residential Street Address (PO Box must include Rural Route or Street Address)
City State ZIP
Date of Birth (applicant must be 18 years old)
mo/day/yr
Telephone w/ area code Email
County of Residence ( Non-residents must list a Minnesota County he or she will be filing in upon receiving their notary commission from the Office of the
Secretary of State)
D. Business Name and Address — This information is optional and applies if notarization is a function of your job
Business Name
Address (Business location where the notary conducts business, PO Box must include rural route or street address) Telephone w / area code
City State ZIP
Choose the address you would like displayed alongside your name on the Office of the Minnesota Secretary of State website.
Failure to indicate a preference will result in an incomplete application.
Residential Business
E. Former Residential Address
(Required if filing an address change. PO Box must include rural route or street address)
F. Former Name (Required if filing a name change. Must attach legal document showing name change, e.g. copy of marriage
certificate, divorce decree, driver’s license, court order, etc.)
For your convenience, this form has been designed to be
completed online. You must have Acrobat Reader 7.0 or above to
use this new feature. Once your form is completed, be sure to
select "Print" at the bottom of the screen to capture your data
entry for printing. After printing, sign and send applicable fees as
required.Note: Selecting "Reset" will clear all data entry from this
page. To print a blank form, go to File->Print.
ALL APPLICANTS MUST ANSWER QUESTIONS 1-4
NOTE: You do not need to answer YES below if the answer is due to an event(s) that occurred PRIOR to your last approved
application to be a notary public and after having submitted the supporting documentation. However, if new issues leading
to a YES response have occurred since then, you must file this Notary Application form, including YES answer(s) and
provide the supporting documentation that is requested.
If the answer to any question is YES, you must attach an explanation including the specific dates, charges, resolution,
attach copies of legal documentation and complete the background check form. All items including these answered
questions, Notary Application, Background Check Form and supporting documentation when applicable, must be mailed
together to the Office of the Secretary of State.
1. Have you ever been the subject of any inquiry or investigation by any state agency?
If yes, submit a written statement explaining the circumstances of incident and copies of
Department letters or order which demonstrate the final resolution of the matter.
YES NO
2.
Have you or has any occupational license held by you been censured, suspended, revoked,
canceled, terminated or otherwise been the subject to any type of administrative action
in any state including Minnesota?
If yes, submit:
A. a written statement explaining in detail the type of license and the circumstances of each incident.
B. a copy of the notice of hearing or other document that states the charges and allegations.
C. a copy of the official document which demonstrates the resolution of the charges or any final judgment.
YES NO
3.
Have you ever been charged with, or convicted of, or been indicted for, or entered a plea to, any criminal
offense (felony, gross misdemeanor or misdemeanor), in any State or Federal Court? You may exclude the
following misdemeanor convictions or pending misdemeanor charges: traffic citations, DUI, DWI or driving
without a license, reckless driving, or driving with a suspended or revoked license. You may also exclude
juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
If yes, submit:
A. a written statement explaining in detail the circumstances of incident, copies of police report and
charging documents. If no longer on file, submit a statement as such from the charging authority on their
letterhead.
B. copies of the sentencing and disposition documents. Register of Actions is not acceptable unless it contains
an official court stamp confirming that it is the only document available. If currently on probation, attach letter
from probation officer stating compliance with terms of probation. If not currently on probation, state you
are not on probation.
YES NO
4.
Have you been a defendant in any lawsuit involving claims of fraud, misrepresentation, conversion,
mismanagement of funds, breach of fiduciary duty or breach of contract?
If yes, submit:
A. a written statement explaining in detail the circumstances of incident.
B. a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or
mediation proceeding.
C. a copy of the official documents, which demonstrate the resolution of the charges or any final judgement.
YES NO
APPOINTMENT OF THE SECRETARY OF STATE AS AGENT FOR SERVICE OF PROCESS. KNOW ALL PEOPLE BY THESE PRESENT:
That in compliance of the Laws of the State of Minnesota, I, the undersigned applicant, if a nonresident, do hereby
appoint the Secretary of State of the State of Minnesota, his/her successor or successors, as my true and lawful agent
upon whom may be served all legal process in any action or proceeding in which I may be a party arising out of or re-
lating to the transactions of the commission, and do hereby expressly consent and agree that service upon such agent
shall be as valid and binding as if due and personal process has been made upon me and that such appointment shall be
irrevocable.
I certify that the statements in this application and attachments are true and complete and that this document has not
been altered or changed in any manner from the form adopted by the Office of the Secretary of State.
OATH: I swear or affirm that I will support the constitution of the United States and of this state to
discharge faithfully the duties of my office to the best of my judgment and ability.
Signature of Notary
Applicant
Date
Print
Reset
INSTRUCTIONS
1. To obtain a Notary commission, submit this completed application with the application fee to the Office of the Secretary of State.
2. The notary commission fee is $120.00. The fee is non-refundable and must be paid by check or money order made payable to the
OFFICE OF THE SECRETARY OF STATE Do not send cash through the mail.
3. Applicant must be at least 18 years of age. Applicant must be either a Minnesota resident, or a resident of a county in IA, ND, SD,
or WI and list the Minnesota County he or she will be filing in upon receiving their commission. Non-resident notary applicants must
designate the Secretary of State as their agent for service of process.
4. Upon receipt of your commission, you must register it with the county. Your resident county name and telephone number will be
listed in the instructions portion of your commission certificate. Please contact the county for directions to the appropriate location
to register your commission. Note: there is a $20.00 fee charged at the county level.
5. Upon receipt of your commission, you must purchase a notary stamp. When you notarize a document, your notary stamp must
match the name on your commission certificate however you may sign documents using your normal signature if different then what
is listed on your commission certificate.
6. Notary commissions expire on January 31 of the fifth year following the year of issue. Applications for renewal may be submitted
6 months prior to the expiration date of your current commission or a reappointment can be made any time after the expiration of
your commission. Upon receipt of your new commission, re-register your commission with the county where you are commissioned,
and purchase a new notary stamp. Your resident county name and telephone number will be printed in the instructions portion of
your new commission certificate. Please contact your county to find out where you should go to re-register. Note: there is a $20.00
fee charged at the county level.
7. Address Changes: You must notify the Secretary of State of any address change within 30 days. If you have changed your home
address to a new county, you must re-register your commission with the county. Your resident county name and telephone number
is listed in the instructions portion of your new commission certificate. Please contact your county to find out where you should go
to re-register and for any fee inquiries.
8. Name Change Application: You must notify the Secretary of State of any name change within 30 days. Please attach your former
commission to this application. You must also attach a copy of a legal document showing the name change (for example, marriage
certificate, divorce decree, or other legal documentation). Upon receipt of your new commission, re-register with the county and
purchase a new notary stamp. Your resident county name and telephone number is listed in the instructions portion of your new
commission certificate. Please contact your county to find out where you should go to re-register and for any fee inquiries.
9. If you answered Yes to any of the 4 questions above, please include the appropriate documentation and return all items to the
Office of the Secretary of State. The Mailing Address is listed at the bottom of this page.
10. Minnesota Statutes, Chapters 357, 358, and 359 (which govern notaries and notarial acts) may be downloaded from the
Minnesota Legislature website www.leg.state.mn.us or purchased through the Minnesota Bookstore (phone 651-297-3000).
11. If you have any questions, please call 651-296-2803 (toll free at 1-877-551-6767) and press option 3 for notary assistance.
MAIL TO:
Minnesota Secretary of State – Notary
Retirement Systems of Minnesota Building
60 Empire Drive, Suite 100
St. Paul, MN 55103
All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If that
information is not included, your document may be returned unfiled. This document can be made available in alternative formats, such as
large print, Braille or audio tape, by calling (651)296-2803/voice. For a TTY/TTD (deaf and hard of hearing) communication, contact the
Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)296-2803. The Secretary of State’s Office does not dis-
criminate on the basis of race, creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public
assistance or political opinions or affiliations in employment or the provision of service.
10
/2019
Criminal Background Check Form
This form only needs to be completed by notary public applicants if there is a YES answer to any of the four
questions listed on the signature page of the notary application.
The Department of Commerce uses this information to conduct criminal history checks.
PLEASE PRINT
Provide complete legal name of applicant
Last Name First Name Middle Name
Date of Birth (mo/day/yr)
Type of Application
Notary Commission
THE FOLLOWING CERTIFICATION AND AUTHORIZATION MUST BE SIGNED BY APPLICANTS
AUTHORIZING A BACKGROUND CHECK:
I, the undersigned, have made application to the Office of the Secretary of State for a regulated
notary commission.
I certify that I have provided complete and accurate answers to all questions on my application.
I hereby request/authorize the Department of Commerce to conduct a background check of me
through their records for licensing or notary commission purposes.
Signature of Applicant Date
MAILING INSTRUCTIONS:
This form should be completed and mailed along with the Notary Application to:
Minnesota Secretary of State - Notary
Retirement Systems of Minnesota Building
60 Empire Drive, Suite 100
St. Paul, MN 55103
10/2019
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Completed 7 November 2020

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