COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF STATE
Harrisburg, PA 17120
(717) 787-5280

ORDER FORM
FOR
OBTAINING THE ACTIVE NOTARY PUBLIC DATA FILE

Active notary public data files for the Commonwealth of Pennsylvania are currently available to the public on CD ROM.

INSTRUCTIONS
1. Please read the file layout enclosed.
2. Complete this order form and submit it along with the appropriate fee.
          -The cost per data file copy is $50.00.
          -Check or money order should be made payable to the "Commonwealth of Pennsylvania".
3. The requesting party must sign and date the form.
4. Mail your completed order to:
          Bureau of Commissions, Elections & Legislation
          Room 210 North Office Building
          Harrisburg, PA 17120
5. Your completed order will be mailed out first class via the U.S. Postal Service.
          -If you wish to use a courier service for the return of your order, please supply a
                prepaid, self addressed, air bill or mailing label when you submit your order.

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Name of Requestor:__________________________________________________________

Organization/Business Name:___________________________________________________

Mailing Address:____________________________________________________________

_______________________________________________________________________________

I have reviewed the data layout that was provided and acknowledge that it is the sole responsibility of the requesting party to load the data for use as provided in this format.

____________________________________________________
Signature of Requestor Date