State Of North Carolina Department Of The Secretary Change Of Name Form
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State of North Carolina
Department of the Secretary of State
Elaine F. Marshall, Secretary of State
NORTH CAROLINA NOTARY PUBLIC
CHANGE OF NAME/ADDRESS/CONTACT INFORMATION FORM
PLEASE PRINT IN INK OR TYPE
The Notary Public Section is available for assistance from 8:00 arn to 5:00 pm, Monday through
ASSISTANCE:
Friday, with the exception of holidays. You may contact us at (919) 807-2219.
NO FEE FOR CHANGE OF NAME / ADDRESS / CONTACT INFORMATION FORM.
FEE:
Notary Public Section
MAIL FORM TO:
Department of the Secretary of State
PO Box 29626
Raleigh, NC 27626-0626
Check the block or blocks that apply:
Change of Name
Change of Address
Changed/Updated Other Contact Information (e-mail, phone numbers, fax, etc.)
ff ''both'' name and county are beina chan-ged simultaneously use the Application for Reapnointment Form.
1. Full Legal Name: (First, Middle/Maiden, Last)
Male
Female
3. County of Commission:
4. Date of Birth:
2. Commissioned Name:
City:
S. Old Mailing Address:
State:
Zip:
6. Old Residence Address:
City:
State:
Zip:
7. Social Security Number:
8. E-Mail Address:
9. New Name on Commission:
I 0. New County of Commission:
City:
I 1. Now Mailing Address:
State:
Zip:
City:
12. New Residence Address:
State:
Zip:
13. Old Business Address:
City:
State:
Zip:
City:
State:
Zip:
14. Now Business Address:
15. Business Phone Number:
16. Home Phone Number:
17. Fax Phone Number:
( )
(
)
(
)
(Your signature on this form does not have to be notarized )
Signature of Applicant:
Date:
INSTRUCTIONS ON THE BACK OF FORM
.
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