Mail or Fax completed form to:
Office
of
the
Great
Seal
7064
Crowner
Drive
Lansing,
MI
48918
Email: [email protected]
Fax: (517) 241-1820
MICHIGAN DEPARTMENT OF STATE
OFFICE
OF
THE GREAT SEAL
D
D
Please check one:
(NO FEE)
Information change
Wallet size Blue Certificate
&
Wall Certificate (81/2 x 11)
NOTARY REQUEST
FOR
DUPLICATE/NOTICE
OF
CHANGE
Ori2inal information (Type
or
print;
complete all sections)
1.
Driver's license or personal identification card number:
Issuing state:
2.
Name
as
currently commissioned:
·
3.
My current commission expiration date: (month/day/year)
New information (Complete only those sections
that
are
changing.)
4. Driver's license or personal identification card number:
Issuing state:
5. Full name (first/middle/last):
(must match your State Driver's License or ID card)
6.
New commission name:
(name
as
it will appear on documents you notarize)
7.
Residence address:
City: State: Zip:
(Must match your Driver's License/ID card, include PO box, Lot and Apt. numbers)
*Please Note: A resident address change that results in a county change Does Not change your
county
of
commission
8.
E-mail-address:
·-
9.
Business address: City:
State: Zip:
10. Telephone numbers:
Residence:
Business:
11.
ELECTRONIC AND REMOTE NOTARY
YES
NO
D
D
Will
you
be
performing electronic notarial
acts?
DO
If
"Yes," identify
the
approved
system
you
intend
to
use:
Will
you
be
performing
remote
rmtarial
acts?
If
"Yes," identify
the
approved
system
you intend
to
use:
1 understand that
all
information contained on this application
is
subject
to disclosure under the Freedom of Information
Act,
1976 PA 442,
MCL
15.231,
et
seq.
If
1 am a licensed attorney, I certify that I am
in
good standing
with
the
State Bar
of
Michigan.
OTHER
CHANGES:
SIGNATURE:
Additional changes not listed above.
Sign your name,
as
it will appear on documents you notarize. I understand
that my signature must appear exactly as I have signed for the duration
of
this commission.
