Home Improvement Registration Application Form Page 2
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1
2AFFIDAVIT
I certify under penalty of perjury under the laws of the State of Louisiana that all statements, answers
and representations in this application, including all supplementary statements attached thereto, are
true and accurate to the best of my knowledge and belief and acknowledge that any purposeful false
information submitted on behalf of myself and/or this applicant and verified by this signature is cause
to have registration denied or revoked by the State Licensing Board for Contractors.
Please complete the appropriate section below. TYPE or PRINT all names.
_______________________________________________________________
Sole Proprietor
_______________________________________________________________
Name of Limited Liability Company
Member: _____________________________ Member: ______________________________
Member: _____________________________ Member: ______________________________
______________________________________________________________
Name of Partnership
Partner:_____________________________ Partner:________________________________
Partner:_____________________________ Partner:________________________________
_______________________________________________________________
Name of Corporation
____________________________________
_____________________________________
Secretary
President
State of _______________________________ Parish or County of _______________________________
Personally appears ____________________________________________ being duly sworn, deposes and saith:
That the foregoing statements of the above-named applicant and all statements therein contained are true and
correct and the answers of the foregoing are true to the best of my knowledge under penalties of perjury.
__________________________________________________
Signature of Applicant/Authorized Representative
__________________________________________________
Social Security Number
Sworn before me this _______________ day of _______________, ________.
__________________________________________________
Signature of Notary Public
______________________________________________________________
Print Name and Address of Notary Public
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