Fillable Home Improvement Registration Application Form printable pdf download

STATE OF LOUISIANA

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STATE LICENSING BOARD FOR CONTRACTORS

2525 QUAIL DRIVE

BATON ROUGE, LOUISIANA 70808‐9042

PHONE (225) 765‐2301 FAX (225) 765‐2690

HOME IMPROVEMENT REGISTRATION APPLICATION

DO NOT WRITE IN THIS SPACE – OFFICIAL USE ONLY

THERE WILL BE NO REFUND OF

APPLICATION FEE.

Date Received _____________ Fee: __________ Check #:___________

Person Making Entry ________________________________________

YOU MUST ANSWER EVERY QUESTION.

[If space provided is not sufficient, use

Date Registration Valid ________________ Regis. #: H____________

separate sheet(s) and attach.]

Misrepresentation of information supplied by an applicant shall be deemed sufficient cause for denial of application.

Application must be accompanied by the required fee. Application must be printed or typewritten in black ink.

PRINT NAME OF INDIVIDUAL OR FIRM AS YOU WISH IT TO APPEAR ON REGISTRATION. APPLICANTS MUST CONDUCT

THEIR CONTRACTING BUSINESS UNDER THE EXACT NAME SHOWN UPON THEIR REGISTRATION CERTIFICATES

Name of Applicant (Full Legal Name of Sole Proprietor, Corporation, LLC, or Partnership)

Physical Address (Street Name and No.)

City

State

Zip Code

ADDRESS OF

PRINCIPAL

PLACE OF

Mailing Address (P.O. Box or Street Address)

City

State

Zip Code

BUSINESS

ENTITY

□

Sole Proprietor

Corporation

Limited Liability Company

Partnership

Limited Liability Partnership

TYPE:

Phone No.

FAX No.

including

Area Code:

E-mail Address

Website Address

Social Security Number for Sole Proprietor/Federal ID Number for Firm

NOTE: failure to provide SSN or Federal ID may result in the denail of your registration.

List names and addresses of any and all owners, partners, or trustees of the applicant including

officers, directors and majority shareholders. (This is not required of publicly traded companies).

Name:

Title:

Social Security No.:

Address:

YOU MUST ANSWER YES OR NO TO QUESTIONS 1-5

YES

Has the applicant been previously registered in LA as a home improvement contractor? If yes,

provide all other names under which the applicant has been registered.

Has the applicant’s registration ever been suspended or revoked?

Are there now any liens, judgements, garnishments or attachments pending or recorded against you, or against any

firm in which you had interest at the time such indebtedness was created, or against any property involved under

any of your contracts arising our of your previous operations in ANY state?

4. Have you or principals in your firm been convicted of a felony or a misdemeanor other than

a violation of traffic laws? If yes, explain on a separate sheet and attach.

Are you involved as a defendant in any pending legal actions?

*SUBMIT THE FOLLOWING REQUIRED INFORMATION*

• Proof by certificate of current general liability insurance in the amount of $100,000 and worker’s compensation

insurance in the exact name which shall appear on the registration certificate emailed to

Insurance@lslbc.louisiana.gov. Under the heading of “Description” your agent must state that the Commercial

General Liability Policy represented on the Certificate of Insurance provides general liability coverage for

residential home improvement contracting operations subject to the terms and conditions of the policy. This

certificate must show effective/expiration dates and limits of coverage and the holder as the State Licensing

Board for Contractors, 2525 Quail Drive, Baton Rouge, Louisiana 70808-9042.

• A $75 check or money order made payable to: Louisiana State Licensing Board for Contractors.

• If corporation or LLC, attach proof that your company is registered with the Louisiana Secretary of State. You

may contact that agency at (225) 925-4704.

• Additional documentation requested in questions above.

Home Improvement Registration Application Form

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