OFFICE OF THE SECRETARY OF STATE

ALABAMA CIVIL‑LAW NOTARY ANNUAL REPORT

Form ACLN‑3

Effective xxxxxx xx, xxxx

Full Name: ____________________________________________________________

1. (Last)                       (First)                  (Middle)

   Business Address:   ___________________________________________________

   (Street)

   ___________________________________________________

2. (City)                      (State)        (Zip Code)

   Business Phone: (   )_____________

   Please provide the name and business address (P.O. Box or Mail Drop Box not acceptable) of an Alabama Civil‑Law Notary who has agreed to take custody of your protocol in the event your appointment is ever suspended or revoked, or you die or become incapacitated:

   ______________________________________________________________________

   ______________________________________________________________________

   Please attach to the application an application processing fee in the amount of $100.00.

   CERTIFICATION

   I hereby certify that the information indicated on this application is true and accurate and that I understand any false statements herein constitute a violation of $13A‑10‑102, Code of Alabama (1975). I further certify that I am eligible to be appointed an Alabama Civil‑law Notary, and that my name appears on this application as an Alabama Civil‑law Notary.

   _________________________________________________________________

   (Print of Type Legal Signature of Applicant)

   _________________________________________________________________

   (Legal Signature of Appointee as it will appear on notarial acts)

   _________________________________________________________________

3. (Date)

   Office of Secretary of State · P.O. Box 5616 · Montgomery, Alabama 36103‑5616