Louisiana Notary Public Application Form

01 Jul, 2017 louisiana, notary-public, Secretary of State 0

In the case of wanting to apply for the Notary Public position in the State of Louisiana, the following form has to be completed and submitted along with a $25 fee.

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Page 1

Tom Schedler
Secretary of State

Application to Qualify for Appointment as Notary Public
La. R. S. 35:191(C)
Enclose $ 25 application fee
Make remittance payable to
Secretary of State
Do not send cash
Return to:

Phone:
Web site:
Notary Divisio n
P.O. Box 94125
Baton Rouge, LA 70804 -9125
Physical Address:
8585 Archives Avenue
Baton Rouge, LA 70809 (225) 922 -0507
www.sos.la.gov

SECTION ONE A. CERTIFICATE OF AGE , RESIDENCE , AND LOCATION OF OFFICE
* * * TYPE OR PRINT LEGIBL Y * * *
Full Lega l Name
Parish of Residence
(Domicile)

Parish of voter
registration
ERIN
Verified

Residence Address Street City/Zip
Mailing Address
(if different from residence ) Street City/Zip
Previous Address
(if current is less than 5 years)
Street or PO Box City/Zip
Telephone
Numbers
Home Cell
Date of Birth
Social Security # (last 4 digits)

Email Address
Current Primary
Employment
Name of Employer Job title or position
Street City/Zip
Phone
Additional current
employment
Name of Employer Job title or position
Street City/Zip
Phone

B. DECLARATION OF STATUTORY QUALIFICATIONS FOR APPOINTMENT
Country of Citizens hip If you are not a US citizen, check the box on right and
attach an original or certified true copy of INS
documentation certifying your legal status as a
resident alien.

Language Proficiency I hereby declare that I read, write, speak and am suffi ciently knowledgeable of
the English language  Yes  No

Page 2

SECTION TWO

ATTESTATION OF GOOD MORAL CHARACTER , INTEGRITY , AND SOBER HABITS
Answer ALL questions, and furnish complete details of any "Yes" answer(s) on the
Supplemental Information Form - SECTION SEVEN A. Have you ever held a commission as a notary in Louisiana not disclosed elsewhere on this application?
If yes, furnish commission parish, date, and name and report the current status of that commission .
Yes No

B. Have you ev er been convicted of any crime (other than as a juvenile) (whether misdemeanor or felony) in any state,
the United States, or foreign state? If so, provide the date of the conviction, the court in which you were convicted, the
actual charges of which you w ere convicted, and the facts surrounding the crime.

C. Have you ever been a party to any lawsuit, court or administrative proceeding –whether civil, criminal, or combination
of both –in which you were accused of being dishonest or making a false stat ement? If so, provide the caption of the
lawsuit, the court or agency in which the proceeding was brought, the allegations against you, and the disposition of the
proceeding.

D. Has any surety on any bond on which you were the principal been requi red to pay any money on your behalf? If so,
provide the name and address of the surety, the name and address of the party to whom monies were paid, and the
amount of the claim and the date you reimbursed the surety.

E. Have you ever filed a petitio n for bankruptcy and been denied discharge from any debt? If so, provide case
information including the name and address of the court, any trustee, and, with respect to debts not discharged, the
names of creditors and amounts not discharged in the proceedi ngs that remain unpaid.

F. Have you ever been disbarred, suspended, censured, or otherwise reprimanded or disqualified from practice in any
profession or as a holder of public office? If so, provide name of entity issuing sanctions, dates, summary of incident,
and ultimate disposition.

G. Have you ever been the subject of any formal charges concerning your conduct as an attorney, or conduct in any
profession? If so, provide name of entity with whom complaints were filed, dates, summary of ch arges, complaints, or
grievances, and ultimate disposition.

H. Have you ever been the subject of any formal charges alleging that you engaged in the unauthorized practice of law,
including any now pending? If so, provide name of entity having juris diction over such charges, dates, summary of the
charges, complaints, or grievances, and disposition.

I. Have you received any discharge from military service other than honorable discharge, or were you court -martialed,
allowed to resign in lieu o f court -martial, awarded non -judicial punishment, or administratively discharged? If so, provide
complete details including branch of service, dates, place where proceedings were filed, and disposition.

J. Have you ever been the subject of any hono r code violation proceeding in any educational institution? If so, provide
name of institution, dates, summary of the incident, and disposition.

K. Have you ever been denied a license for business, trade, or profession (e.g. CPA, real estate broker , physician,
patient practitioner, etc.)? If so, provide details including name of authority denying license, type of license, date and
reasons for denial, and whether appeal was taken and disposition, if any, of appeal

L. Have you ever had a busin ess, trade or professional license revoked? If so, provide name of authority revoking
license, date, and reasons for revocation.

M. Have you been charged with any alcohol or drug -related traffic violations during the past 10 years? If so, provide
complete details including dates, nature of violation, and disposition.

Answers to questions below are confidential and protected by law from public disclosure.

N. W ithin the past five years, have you ever raised the issue of consumption of drugs or alcohol or the issue of a
mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation, or explanation for your actions
in the course of any administrative or judicial proceeding or investigation, any inquiry, or oth er proceeding; or any
proposed termination by an educational institution, employer, government agency, professional organization, or license
authority? If your answer to the question above is yes, furnish complete details.

O. Have you ever been ter minated, suspended, disciplined, or permitted to resign in lieu of a termination from any job
due to fraud, alcohol, drug abuse or any other charges of misconduct ? If yes, provide the name of the employer, dates
of employment, and fully explain the circums tances.

Page 3

SECTION THREE
(check only one )
EXEMPTION FROM EXAMINATION
La. R.S. 35:191(C)(2)(c) or La. R.S. 35:191(E)
Office use
 Attorney admitted to the
practice of Law in the State
of Louisiana
Applicant is duly licensed to practice law in the State of Louisiana, and is
exempt under R.S. 35:191(C)(2)( e) from taking or passing the Louisiana state
notary examination provided for in R.S. 35:191.1.
Status verified by: Approv al Date :

 Notary currently
commissioned in the State
of Louisiana seeki ng a dual
commission
Applicant currently holds a valid commission as a notary public in the State of
Louisiana in and for the Parish of _____________________, and is exempt
under R.S. 35:191(C)(2)( e) from taking the Louisiana state notary
examination pro vided for in R.S. 35:191.1.
Status verified by: Approv al Date :

 Notary /Attorney Notary
currently commissioned in
the State of Louisiana
changing parish of
residence
Applicant ho lds or has held a valid commission in and for the Parish of
_____________ ____, and is changing his residence /office location to
_________________ parish, and is exempt under R.S. 35:191 (E) from taking
or passing the Louisiana state notary examination provided for in R.S.
35:191.
Status verified by:

Approv al Date :
EXAMINATIO N REQUIRED – La. R.S. 35:191. (C)(2)(b)
 New Applicant
Examination Registration
The undersigned applicant declares that he has met the requirements for
appointment to the office for which he has applied and hereby requests
approval to register to take th e Louisiana state notary public examination
provided for in R.S. 35.191.1
Examination Registration requires a separate $75 examination fee
Status verified by:

Approv al Date :
SECTION FOUR
AFFIDAVIT OF APPLICANT

STATEMENT of APPLICANT

I, _____________________________ , herein applying to qualify for appointment to the office of Notary Public
in and for the Parish of ____ ________ ______________ , do state that the information contained in this appl ication and
in all supplemental forms and attachments hereunto are true and complete and given for the purpose of obtaining
appointment to the office Notary Public under the provisions of R .S. 35 et seq.

________________________________________________
Applicant signature

________________________________________________
Applicant printed name

Page 4

SECTION FIVE

ATTACHMENTS - CHECK ALL THAT APPLY

 Notary Public Examination Registration (along with separate $75 examination fee)
 Proof of Immigratio n Status
 Letter of Good Standing from Supreme Court
 Supplemental Information Form (for SECTION TW O questions)

SECTION SIX

SECRETARY OF STATE USE ONLY

 Date received: ____ ____ ______________

Fees received :
 $25 qualifying application f ee  $75 exam registration fee  $35 commission filing fee

 Court Approval Required

 Date Approved: _____ _______ ___________ _____ _

 Approved by: _________ __ ___ _____________ __ __

Page 5
SECTION SEVEN SUPPLEMENTAL INFORMATION FORM
A.

(If more space is needed use a blank piece of paper)

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