..

b For BB0BD SBLDy

SECHETAHY OF b1ATE
Retirement Systems of MN Building
60 Empire Drv. Suite 100
St. Paul. MN 5513
51-29-203(toll free at 1-7-5516767)
Press Option 3
Email: nota .sos state.mn.us
NOTARY COMMISSION
APPLICATION
DB DBB WDCD yCU |UHSD CD D|S |0F0 Wl 0B USBD Dy DB Ll|ICB C DB OBCFBBIy Cl OBB BRD\DB LBBl0BD Cl LC0RBFCB C
BSSBSS yCUF QUBICB|CNS for a commission. After issuance C the commission your name and designated address |S public
pursuant to MinDesCUbU\utes, Ch8p1Bt14.
A. APPLICATION (Check applicable box)
D NEW 0 REAPPOINTMENT
APPOINTMENT Fee: $120
Fee: $120 (comission has expired)
D RENEWAL
Fee:S120
(can also be renewed onllne
at notary.sos.state.mn.us)
D ADDRESS CHANGE
No Fee
(can also update online at
notary.sos.state.mn.us)
B. COMMISSION NUMBER [BqUIFBD CF FBBClDRBD, lBDBWB, BDDFBSS CDBRgB BRD B0BCDBDgB)

CURRENT COMMISSION NUMBER
02Gc8?
NAME CHANGE
No Fee
(attach legal
documentation)
C. APPLICANT INFORMA TlON [LIS yCUl DBRB RB WBy BBBFS CD yCUI DIlVBS CCDSB, BX FBUlRS aDDlBgBl DCC0BRS.)
FIRST NAME MIDDLE NAME OR INITIAL LAST NAME
c l Vr1.cze
RESIDENTIAL STREET ADDRESS (PO Box must Include Rural Route or Street Address)
I 4h Pa NW
STATE
DA TE OF BIRTH
|
((pl nt must 1years old)
mo/daytyr:
0 7 a 7
TELEPHONE NUMBER W! area code
(97> J 6
t1
EMAIL ADDRESS
midle.Vr
CODE
tY
COUNTOFRESIDENCE (Non-residents must list a Minnesota County he or she will b fling in upon receiving their notary commission ko the
Ofice of te Seaetary of Slate.)
C
D. BUSINESS NAME AND ADRESS CRB -_IBS WDBR DCBlIZBCRISB |UDCCP of your lo
BUSINESS NAME
T
BUSINESS ADQRESS (Business location where the notary conducts business. PO Box must include Rural Route 0lStreet Address)
llf _ Lr NW
CITY
I
STA
MN
IDO/
TELEPHONE NUMBER WlID area code
( 17) dGd CS 7
Check address you want shown on public list: (Must CDBCK CRB BRD can CDBCK 0CD. If RCDB B!BCDBCKBD, DBBU!!S FBSDBD|B)
D B8DBDBlPDDlBSS 'USDBSSPDDlBSS
FORMER RESIDENTIAL STREET ADDRESS (PO Box must incude Rural Route or Street Address)
copy of marriage certificte, divorce decree. driver's license, court order,
.-
ALL applicants MUST answer questions 1-4.
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 guestions1 Notar Aication1 Background Check Form and
suring documentation when aicable1 must be mailed together to the Office of the Secretar of
State.
1. Heve you ever been lhesubject of any Inquiry C!Investi gation wlh reSpeCIC a notary cqmmission or by ny
YES NL
division of the Minnesota COmme| OCpat!menI[ yOS, aUaO w|ROn explanatiCn and copies of OCp|!menl
D
letters or order.)
Z. Have you or has any ocupational ||nSC held by you been nSu|Cd, suspended, revoked, cnceled,
YES NO
terminated or been the subjec to any type of administrative action in any state including Minnesota? (If yes,
D

attach written explanation and cpies of Departent letters or order.)
. Have you ever been charged with, or convicted of, or ben indicted for. or entered a plea to, any criminal offense
YES NO
(felony, gross misdemeanor or misdemeanor), in any State or Federal LCuC? (If yes, attach written
D

explanation and copies of complaint, sentencing and disposition documents, and if currently on
probation, atach leer from probation officer stating compliance with tens of probaton.) Note: Thi
does NOT Include trafic violations such as DUI DWI Sln- etc.
4. Have you been a defendant in any lawuit involving CBI0SClIBUC, misrepresentation, CCDVBFSCD,
YES NO
mismanagement of funds, breach of fduciary duty or breach Ccntract (If yes, attach written explanation and
0
w
copies of cur documents.)
APPOINTMENT OF THE SECREARY OF STATE AS AGENT FOR SERVICE OF PROCESS. KNOW ALL PEOPLE BY THESE PRESENT:
Tat In compliance o!the Laws of the State of Minnesota, I, the underigned applicant, If a nonresident. do hereby appoint !he Secretary of Stale of
m State of Minnesota, hiser succssor or sucssC|s. as my !rue and lawful agent upon whom may be served all legal procss in any acn or
proceding inwhic I may be a party arising ouIof or relating to the tansactions of the cmmission, and do hereby expressly consent and agr0e!hat
service upon such agent shall be as valid and binding as if due and personal process has been made upon me and that suCh appolnlment shall be
irrevocble.

I cr tat 0 statements In this appliction and attacments are true and complete and tat thi domnt has not ben altere or
changed in any manner from the K0 adopted by the Offc of the Secretary of S
_
tate.
OATH: I swear to uphold the duties of a Notary Public in the State of Minnesota.
Date