EMPIRE NOTARY – Mobile Notary Service Request

EMPIRE NOTARY – Mobile Notary Service Request

Private. Discreet. Legally Exact. Complete this secure intake to request an in-person mobile notary appointment. Submitting this form does not confirm an appointment or final price. Empire Notary will review your information and send a quote, payment link, or next-step instructions.
Client Information
Full Name

First NameMiddle NameLast Name
Email Address
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Are you the signer?
Signer’s Full Name

First NameMiddle NameLast Name
Signer’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Relationship to the Signer
Appointment Request
Preferred Appointment Date

MonthDayYear
Date
Preferred Appointment Time

Hour Minutes

AM/PM Option
Appointment Flexibility
How soon do you need service?
Alternate Appointment Date

MonthDayYear
Date
Alternate Appointment Time

Hour Minutes

AM/PM Option
Service Location
Street Address
Apartment, Suite, Room, or Unit Number
City
State
ZIP Code
Location Type
Parking, toll, gate, security, elevator, or access requirements
Contact Person at the Location
Contact Person’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signer Information
Number of Signers
Full Name of Each Signer
Will every signer be present at the appointment?
Does every signer have a valid, unexpired government-issued photo ID?
Please explain the identification concern.
Can every signer communicate directly with the notary and clearly indicate willingness to sign?
Can every signer physically sign the document without assistance?
Is an interpreter needed?
Interpreter’s Name
Language Needed
Interpreter’s Relationship to the Signer
Is the signer currently in a hospital, senior living facility, rehabilitation facility, or under medical care?
Facility Name
Facility Room Number
Facility Contact Person
Are there visiting restrictions?
Is staff approval required before arrival?
Do not provide medical diagnoses or unnecessary medical records. Empire Notary only needs information required to access the signer and conduct the appointment properly.
Document Information
General Document Type
Document Title or Brief Description
Number of Documents
Estimated Number of Notarizations
Estimated Total Page Count
Are the documents complete and ready for signing?
Have any documents already been signed?
Lead Status
Quote Status
Payment Status
Appointment Status
Follow-Up Date

MonthDayYear
Date
Assigned Notary
Travel Tier
Estimated Total
Intake Source
Should be Empty:

EMPIRE NOTARY – Mobile Notary Service Request

Client Information

Appointment Request

Service Location

Signer Information

Document Information