Transmittal Information For All Notary Filings - Louisiana Secretary Of State (Page 3 of 6) in pdf

, I

SECTION TWO

TTESTATION OF

OOD

ORAL

HARACTER

NTEGRITY

AND

OBER

ABITS

Answer ALL questions, and furnish complete details of any "Yes" answer(s) on the

Yes

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.

B. Have you ever 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 were 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 statement? 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 required 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 petition 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 proceedings 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 charges, 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 jurisdiction 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 of 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 honor 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 business, 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. Within 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 other 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 terminated, 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 circumstances.

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Transmittal Information For All Notary Filings - Louisiana Secretary Of State Page 3

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