Transmittal Information For All Notary Filings - Louisiana Secretary Of State Page 2
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6Application to Qualify for Appointment as Notary Public
Tom Schedler
La. R. S. 35:191(C)
Secretary of State
Return to:
Notary Division
Enclose $25 application fee
P.O. Box 94125
Make remittance payable to
Baton Rouge, LA 70804-9125
Secretary of State
Physical Address:
Do not send cash
8585 Archives Avenue
Baton Rouge, LA 70809
Phone:
(225) 922-0507
Web site:
A. C
A
, R
,
L
ERTIFICATE OF
GE
ESIDENCE
AND
OCATION OF OFFICE
SECTION ONE
* * *
* * *
TYPE OR PRINT LEGIBLY
Full Legal Name
Parish of Residence
(Domicile)
ERIN
Parish of voter
registration
Verified
Residence Address
Street
City/Zip
Mailing Address
Street
City/Zip
(if different from residence)
Previous Address
Street or PO Box
City/Zip
(if current is less than 5 years)
Telephone
Home
Cell
Numbers
Date of Birth
Social Security # (last 4 digits)
Email Address
Current Primary
Name of Employer
Job title or position
Employment
Street
City/Zip
Phone
Name of Employer
Job title or position
Additional current
employment
Street
City/Zip
Phone
B. D
S
Q
A
ECLARATION OF
TATUTORY
UALIFICATIONS FOR
PPOINTMENT
Country of Citizenship
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.
I hereby declare that I read, write, speak and am sufficiently knowledgeable of the
Yes
No
Language Proficiency
English language
I have received a high school diploma, a diploma for completion of a home study
program approved by the State Board of Elementary and Secondary Education or
Education
Yes
No
a high school equivalency diploma after successfully completing the test of
General Educational Development.
Page 1
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