EMPIRE NOTARY – Remote Online Notarization Request

1
Client Full Name
First Name
Last Name
2
Client Phone Number
Please enter a valid phone number.
3
Client Email Address
example@example.com
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Preferred Method of Contact
Text
Email
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Preferred Appointment Date* This field is required.
Date
Month
Day
Year
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Preferred Appointment Time* This field is required.
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Hour
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Minutes
AM
AM
PM
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Time Zone* This field is required.
Please Select
Please Select
Eastern
Central
Mountain
Pacific
Alaska
Hawaii
Other
8
Appointment Flexibility* This field is required.
Exact time required
Flexible within one hour
Flexible within two hours
Flexible anytime that day
9
How soon do you need service?* This field is required.
Standard scheduling
Same-day
Emergency
After-hours between 7:00 PM and 2:30 AM
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Alternate Appointment Date
Date
Month
Day
Year
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Alternate Appointment Time
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2
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Hour
40
00
10
20
30
40
50
Minutes
AM
AM
PM
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Are witnesses required?
Yes
No
Unsure
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Do you need a witness for your Remote Online Notarization?* This field is required.
Yes
No
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Number of Witnesses Needed
15
Will the client provide the witnesses?
Yes
No
Some witnesses are already arranged
16
Do you need Empire Notary to coordinate witnesses?
Yes
No
Unsure
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Are there lender, title, attorney, or corporate instructions that must be followed?
Yes
No
Unsure
18
Copy Paste or describe the instructions.
19
Upload Finalized, Unsigned Documents
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload Documents
PDF, DOC, DOCX, JPG, PNG; max 10 MB
Cancelof
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Please review and acknowledge the following by selecting all statements below.* This field is required.
I understand that submitting this form does not confirm an appointment.
I understand that Remote Online Notarization may not be available for every document, jurisdiction, signer location, or receiving organization.
I understand that I am responsible for confirming whether the receiving organization accepts Remote Online Notarization.
I understand that every signer must be physically present on camera for the session and must provide acceptable identification.
I understand that the Remote Online Notarization platform may conduct identity verification, credential analysis, knowledge-based authentication, ID capture, video recording, and audit-trail creation.
I understand that failure to complete identity verification may prevent the notarization from proceeding.
I understand that all signers must use a working camera, microphone, supported device, stable internet connection, and private environment.
I understand that documents should remain unsigned until instructed during the session.
I understand that Empire Notary does not provide legal advice, select documents, interpret document terms, explain loan terms, or prepare legal instruments.
I understand that questions concerning legal meaning, loan terms, document selection, or transaction terms must be directed to an attorney, lender, title representative, or other authorized professional.
I understand that incomplete documents, blank spaces, missing signers, unacceptable identification, coercion concerns, communication limitations, technology failure, or receiving-party restrictions may prevent the session from proceeding.
I understand that same-day, emergency, after-hours, witness, identity-verification reset, or specialized transaction fees may apply.
I consent to receive appointment-related text messages, emails, and phone calls from Empire Notary.
I consent to the use of the approved Remote Online Notarization platform and any legally required recording or audit trail.
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Lead Status
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Eligibility Status
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Receiving-Party Acceptance
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Identity Readiness Status
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Technology Readiness Status
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Quote Status
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Payment Status
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Session Status
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Platform Assignment
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Assigned Notary
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Follow-Up Date
Date
Month
Day
Year
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Estimated Total
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Intake Source
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Client or Authorized Representative Signature* This field is required.
35
Date Submitted* This field is required.
Date
Month
Day
Year
36
I consent to Empire Notary using my feedback or description of my experience for marketing or social media, without sharing my full name, contact information, or confidential document details.* This field is required.
I consent to Empire Notary using my feedback or description of my experience for marketing or social media, without sharing my full name, contact information, or confidential document details.
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Country
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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State
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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What type of document do you need notarized?
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Who requested this document?
Attorney
Employer
Government Agency
Bank
Title Company
Court
Meta
Facebook
Contest Sponsor
Business
Insurance Company
School
Self
Other
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When do you need this completed?* This field is required.
Today
Within 24 Hours
This Week
Flexible
42
I understand my request will be reviewed before scheduling. I understand that the organization receiving my document determines whether a Remote Online Notarization is acceptable for its requirements. I understand Empire Notary cannot determine or guarantee acceptance by a third party.* This field is required.
I acknowledge these statements.
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