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The document appears to be an application for a notary public license in the state of Minnesota, as it requests information such as the applicant's name, address, date of birth, and answers to questions regarding any past investigations, license suspensions, criminal charges or lawsuits against the applicant. The data provided in the application will be used by the Minnesota Secretary of State and Department of Commerce to review the applicant's qualifications for a notary license.
The document appears to be an application for a notary public license in the state of Minnesota, as it requests information such as the applicant's name, address, date of birth, and answers to questions regarding any past investigations, license suspensions, criminal charges or lawsuits against the applicant. The data provided in the application will be used by the Minnesota Secretary of State and Department of Commerce to review the applicant's qualifications for a notary license.
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Attribution Non-Commercial (BY-NC)
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The document appears to be an application for a notary public license in the state of Minnesota, as it requests information such as the applicant's name, address, date of birth, and answers to questions regarding any past investigations, license suspensions, criminal charges or lawsuits against the applicant. The data provided in the application will be used by the Minnesota Secretary of State and Department of Commerce to review the applicant's qualifications for a notary license.
Droits d'auteur :
Attribution Non-Commercial (BY-NC)
Formats disponibles
Téléchargez comme PDF, TXT ou lisez en ligne sur Scribd
8EHTAHYOF8TATE Empire Dr. Suite 100 St. Paul, MN 55103 (651) 296-2603 Emal!: . Notary.sos@state.mn.us NLPHY LNNlLN PLlPlLN The data which you furish on this form will be used by the Offce of the Secretary of State and the Department of Commerce t o assess your qualifications for a license. Disclosure of your social security number i s voluntary. The Offce or the Deparment may use social security numbrs for identification purposes. Failure to provide the SSN will not prevent your application from being reviewed and granted if otherwise appropriate. After issuance of the commission your name and designated address is public pursuant lo Minnesota Statutes, Chapter 13. P. PLP1lLN(Check applicable box) NEW APPOINTMENT Fee:$40 0 RE-APPOINTMENT Fee: $40 0 ADDRESS CHANGE (No ke) 0 NAME CHANGE (Nofee) Ata lenl docmenlation . PLlPN NlLHNPlLN(please type or print legibly) FIRST NAME 1 MIDDLE ,E OR INITIAL J LAST NAME / /c.1rei. s RESIDENT STREET ADDRESS (PO Box must Incude Rural Route or Street Address) ZlZ 4 C /^ w CITY 7 -./c J sTA M _ J ZIPCODE .S3G DATE OF BIRTH (Appliant mze 16 years old) J TELEPHONE NUMBER wth ar0ae l EMAIL ADDRESS mo/dayr. I 0 f T ( 6.1 ) 2 . 5 8 : fe ve@ ,?, f; ** COUNTOF RESIDENCE (Non-esldent must list t Minnesota County tat l SOCIAL SECURITY NUMBER {optional) borders to non-rosienl County o Residenc} (/' CURRENT COMMISSION NUMBER (required for reappointment or name change or address change) FORMER ADDRESS (4address change) FORMER NAME (Must oltach legal doument showing the name change; i.e. a mamae certe, divorce decree. copy of drrvers license. court Or. etc.) ALL applicants must answer questions 1-4. If the answer to any question Is X, you must attach an explanation Including the specific dates, charges, resolution, and attach copies of legal documentation. 1. 2. 3. 4. Have you ever been the subject of any inquiry or investigation with respect to a notar commission or by any division of the Minnesota Commerce Department? (If yes. attach written explanation and copies of Department letters or order.) Have you or has any occupational license held by you been censured, suspended, revoked, canceled, terminated or been the subject to any type of administrative action in any state including Minnesota? (If yes, attach written explanation and copies of Department letters or order.) Have you ever been charge with. or convicted of, or bee n indicted for. or entered a plea to, any criminal offense (felony, gross misdemeanor or misdemeanor). in any State or Federal Court? (If yes, attach written explanation and copies of complaint, sentencing and disposition documents, and if currently on probation, attach letter from probation off complianc with terms of probation.) Note: 1hl8do08 NOT |6lud8m0v|olatlon8 8uca8 WI 0dl 0tc. Have you been fendant in any lawsuit involving claims of fraud, misrepresentation. conversion, mismanagement of funds, breach of fduciary duty or breach of contract? (If yes, attach written explanation and copies of court documents.) Rev. 9/05 Page 1of2 YL