State of Missouri
John R. Ashcroft, Secretary of State
Commissions
PO Box 784, Jefferson City, MO 65102
Toll-Free (866) 223-6535 or (573) 751-2783
Application for Commission as a Notary Public
(Application fee $25)
Print or Type
1. Name Date of Birth (MM/DD/YYYY)
(This name must appear as it is signed in #18)
2. Home Address
City State Zip Code
3. County of Residence (St. Louis City Residents, please specify St. Louis City)
4. Daytime Phone Number E-mail address
5. Employer/Name of Business
Street
City State Zip Code
6. Missouri Commission Number (if reapplying)
7. Previous Commission Expiration Date (if any)
8. Previous Name (if your name has changed)
Check YES or NO for the following questions:
9. Are you at least eighteen years of age? YES NO
10. Are you a registered voter of the county for which you have applied to be commissioned or a permanent YES NO
resident alien? (Section 245, Immigration and Nationality Act requires that you, attach a copy of your
green card)
11. Do you live in the county within and for which you have requested to be commissioned? YES NO
12. Are you able to read and write the English language? YES NO
13. Have you been refused a commission as a notary public or had a commission revoked? YES NO
(If yes, attach a separate letter indicating reason and date.)
14. Have you ever been convicted of or pled guilty or nolo contendere to any felony? (If yes, attach a list and YES NO
supporting documentation of such convictions or pleas of guilt or nolo contendere.)
15. Have you ever been convicted of or pled guilty or nolo contendere to any misdemeanor incompatible YES NO
with the duties of a notary public? (If yes, attach a list and supporting documentation of such convictions
or pleas of guilt or nolo contendere.)
16. Have you read the Missouri Notary Public Handbook and know the laws and duties of a Notary Public? YES NO
17. Have you completed a state-approved notary training? (Attach your certificate of completion or your
completed written notary training form.) YES NO
18. NOTARIAL OATH
STATE OF MISSOURI
I, the person named above, do swear or affirm, 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 qualified to be appointed and commissioned as a Missouri notary public.
X
Signature of Applicant (Signature MUST appear as it is typed or written in #1 above)
Form Comm. 51 (01/2017) — Page 1 of 2
This form is designed to be filled out online for your convenience.
Complete the necessary information, print, sign and mail.
