TRANSMITTAL INFORMATION
For All Notary Filings
Name of Person Filing Document
Daytime Phone Number
Address
City
State
Zip Code
Fax Number Email Address
Notary Division
(225) 922-0507
Fax Numbers
(225) 932-5359 Notary
STATE OF LOUISIANA
S
ECRETARY OF STATE
Nancy Landry
Secretary of State
Mailing Address: P. O. Box 94125, Baton Rouge, LA 70804-9125
Physical Address: 8585 Archives Ave., Baton Rouge, LA 70809
www.sos.la.gov
SS984N Rev. 01/24
Check or Money Order Enclosed
Use credit card on file*
Last 4 digits of card on file ___________
* Do not include credit card information on this form. To store credit card information on file, navigate to
sos.la.gov/notarysignin, create an account, if necessary, and sign in. Click Update Master Account, and then click
Manage Saved Payments. Please provide your email address and last 4 digits of the stored credit card on this
form so we can retrieve your payment information.
Please indicate payment and contact information below
Page 1
Nancy Landry
Secretary of State
Application to Qualify for Appointment as Notary Public
La. R. S. 35:191(C)
Enclose $35 application fee
Make remittance payable to
Secretary of State
Do not send cash
Return to:
Notary Division
P.O. Box 94125
Baton Rouge, LA 70804-9125
Physical Address:
8585 Archives Ave.
Baton Rouge, LA 70809
(225) 922-0507
www.sos.la.gov
SECTION ONE
A. CERTIFICATE OF AGE, RESIDENCE, AND LOCATION OF OFFICE
* * * TYPE OR PRINT LEGIBLY * * *
Full Legal Name
Parish of Residence
(Domicile)
Parish of Voter
Registration
ERIN
Verified
Residence Address
Street City/Zip
Mailing Address
(if different from residence)
Street City/Zip
Previous Address
(if current is less than five years)
Street or PO Box City/Zip
Telephone
Numbers
Home Cell
Date of Birth
Social Security Number
(last four digits)
Email Address
Current Primary
Employment
Name of Employer
Job Title or Position
Street City/Zip
Phone
Additional current
employment
Name of Employer
Job Title or Position
Street City/Zip
Phone
B. DECLARATION OF STATUTORY QUALIFICATIONS FOR APPOINTMENT
Country of Citizenship
If you are not a U.S. 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.
Language Proficiency
I hereby declare that I read, write, speak and am sufficiently knowledgeable of
the English language
Yes No
Education
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 a high school equivalency diploma after successfully completing the test of
General Educational Development.
Yes No
Page 2
SECTION TWO
ATTESTATION OF GOOD MORAL CHARACTER, INTEGRITY AND SOBER HABITS
Answer all questions, and furnish complete details of any "Yes" answer(s) on the 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, name and report the current status of that commission.
Yes
No
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.
Page 3
SECTION THREE
(check only one)
EXEMPTION FROM EXAMINATION
La. R.S. 35:191(C)(2)(c) or La. R.S. 35:191(E)
Office use
Attorney admitted to the
practice of law in the State
of Louisiana
Applicant is duly licensed to practice law in the State of Louisiana, and is
exempt under La. R.S. 35:191(C)(2)(c) from taking or passing the Louisiana
state notary examination provided for in La. R.S. 35:191.1.
Status verified by:
Approval date:
Notary currently
commissioned in the State
of Louisiana seeking a dual
commission
Applicant currently holds a valid commission as a notary public in the State of
Louisiana in and for the Parish of _____________________, and is exempt
under R.S. 35:191(C)(2)(e) from taking the Louisiana state notary
examination provided for in La. R.S. 35:191.1.
Status verified by:
Approval date:
Notary/attorney notary
currently commissioned in
the State of Louisiana
changing parish of
residence
Applicant holds or has held a valid commission in and for the Parish of
_________________, and is changing his residence/office location to
_________________ parish, and is exempt under La. R.S. 35:191(E) from
taking or passing the Louisiana state notary examination provided for in
La.R.S. 35:191.
Status verified by:
Approval date:
EXAMINATION REQUIRED – La. R.S. 35:191.(C)(2)(b)
New applicant
examination registration
The undersigned applicant declares that he has met the requirements for
appointment to the office for which he has applied and hereby requests
approval to register to take the Louisiana state notary public examination
provided for in La. R.S. 35.191.1
Examination Registration requires a separate $100 examination fee
Status verified by:
Approval date:
SECTION FOUR
STATEMENT OF APPLICANT
STATEMENT of APPLICANT
I, _____________________________, herein applying to qualify for appointment to the office of notary public
in and for the Parish of __________________________, do state that the information contained in this application and
in all supplemental forms and attachments hereunto are true and complete and given for the purpose of obtaining
appointment to the office of Notary Public under the provisions of La. R.S. 35 et seq.
________________________________________________
Applicant signature
________________________________________________
Applicant printed name
Page 4
SECTION FIVE
ATTACHMENTS - CHECK ALL THAT APPLY
Notary Public Examination Registration (along with separate $100 examination fee)
Proof of Immigration Status
Letter of Good Standing from Supreme Court
Supplemental Information Form (for SECTION TWO questions)
SECTION SIX
SECRETARY OF STATE USE ONLY
Date received: ______________________
Fees received:
$35 qualifying application fee $100 exam registration fee $35 commission filing fee
Court Approval Required
Date Approved: _____________________________
Approved by: _______________________________
Page 5
SECTION SEVEN
SUPPLEMENTAL INFORMATION FORM
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
(If more space is needed,use a blank piece of paper.)
