Identity & Contact Information

All information must be accurate and complete.

Personal Identity

Full Legal Name *

Any Other Names / Prior Names / Maiden Names * List all other names you have ever used.

I have never used any other names

Date of Birth *

Place of Birth *

Contact Information

Principal Place of Business Address *

Work Telephone *

Mobile Telephone *

Email Address *

Personal Website URL

Business / Employer Website URL

List each social-media account with which you are affiliated.

Platform

Handle / URL

I have no affiliated personal social media accounts

Platform

Handle / URL

Agent for Service of Process

Service of Process Agent — Name *

Service of Process Agent — Address *

Affidavit of Acceptance (Service of Process Agent) * PDF or Word — required unless previously filed and on record with the Secretary of State.

📄 affidavit.pdf · stubbed Certify already on file with the Secretary of State

Are you a nonresident of Louisiana? * Yes No

As a nonresident, you must appoint and maintain a Louisiana registered agent for service of process (named above) and file evidence of that appointment with the Louisiana Secretary of State. Provide the registered agent's name and address above — you do not need to upload proof of the appointment here.

Current Business & Employer

Are you self-employed? * Yes No

Self-Employment Start Date

Nature of Self-Employment

Employer Name (Full Legal Name) *

Employer Address *

Employer Phone *

Organization Form of Employer *

Nature and Form of Business *

Supervisor Name

Supervisor Contact

Employment Start Date

Additional Affiliated Firms or Organizations

Organization Name

Nature of Business

Address

Country of Origin

Persons with Financial Interest in Your Operation *

Include all partners, associates, officers, managers, profit sharers, or persons with 5% or more ownership or equity interest.

Full Name

Role

Address

None apply

Five-Year Occupation History

List all employment, self-employment, and occupations for the five (5) years immediately preceding this application — including any periods of unemployment.

Employer / Organization

Position / Title

Start Date

End Date

Nature of Business

Address

Professional / Occupational Licenses Held in Past 5 Years *

License / Cert Type

Issuing Authority

Date Issued

Expiration Date

Status

I have held no licenses

Memberships in Business or Professional Organizations

Organization

Dates of Membership

Role

Identity & Contact Information

Personal Identity

Contact Information

Social Media Accounts — Personal *

Social Media Accounts — Business / Employer

Agent for Service of Process

Current Business & Employer

Additional Affiliated Firms or Organizations

Persons with Financial Interest in Your Operation *

Five-Year Occupation History

Professional / Occupational Licenses Held in Past 5 Years *

Memberships in Business or Professional Organizations