Lslbc Verification Of License Page 4
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5State of Louisiana
State Licensing Board for Contractors
2525 Quail Drive, Baton Rouge, LA 70808 1-800-256-1392 Fax (225) 765-2362
REQUEST FOR VERIFICATION OF
Instructions to Applicant: Complete the information in
the section immediately below only and submit this form to
the Board for the state in which you are licensed. Then
submit
the completed
form
to the
Board
with which you
are requesting reciprocal status, along with that Board's
application
(if it has not
already
been
submitted).
TO BE FILLED OUT BY APPLICANT
Company Name/Individual Name:
Address:
City:
State:
Zip Code:
Telephone #:
Fax #:
E-Mail Address:
Name of Contact:
V
L
ERIFICATION OF
ICENSE
Instructions for Verifying State:
The above named applicant has submitted an application for a contractor’s license with this Board.
Please complete the following and return this form to the applicant. If additional space is needed, please use additional pages.
Company/Individual Name:
License #
Type of Firm: Corporation
LLC
Partnership
Sole Proprietor
Original Issuance Date:
Expiration Date:
Current Status(Current/Inactive/Expired)
If Sole Proprietor/Partnership, State of Primary Residence:
State of Original Incorporation If Corp./LLC,
Disciplinary Action? Yes
No
If Yes, Please Explain:
Classification(s) Held:
Trade Exams Passed
Legal Name of EACH Person Passing
Trade Exam in your state for this
Exam Originally
Developed By
company. If no exam was taken in your
Date
Classification
(e.g. NAI,
Score
state for a classification, please explain the
Passed
Block, SBCCI,
reason, and show the name of the
AMP, Prometric,
qualifying party(ies).
In-House, etc
.)
S
TATE
Signature:
Date:
Title:
S
EAL
Agency:
Telephone #:
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Revised 9.13.2017
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