Fillable Home Improvement Registration Application Form

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Home Improvement Registration Application Form

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The Home Improvement Registration Application Form form is 5 pages long and contains:

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  • 68 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Louisiana

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1
Revised 05/29/2019
INSTRUCTIONS PAGE
1.
Save this application to your computer before you begin.
2. Complete the application.
Sections 1 – 4 must be completed as instructed.
Every question must be completed. If a question is not applicable, indicate.
If a space provided is not sufficient, attach separate sheet(s).
3. All signatures must be notarized.
4. Social Security Numbers, Dates of Births, Tax ID’s must be provided where required.
Failure to provide this information where requested may result in denial of your application.
Your SSN/Taxpayer ID will not be released for any other purpose not provided by law.
5. Louisiana Secretary of State Charter Number must be provided.
(Excluding Sole Proprietor and General Partnerships)
LLCs, Corporations, and Limited Partnerships must be registered with the Louisiana Secretary of State
(LA SOS)
Joint Ventures are not required to be registered with the LA SOS but if you have registered, then you
must provide your Charter Number
6. A company email address MUST be provided. No exceptions!
LSLBC will be sending letters, registration renewals, and other correspondence to the email
address provided.
Be sure to keep your email address up-to-date.
7.
Misrepresentation of information supplied by an applicant shall be deemed sufficient cause for denial of
application or revocation of registration and/or subject to criminal prosecution for making false official
statements, in accordance with LA R. S. 14:133.
8. Application must be accompanied by the required $75.00 Application fee. Fees are NONREFUNDABLE.
9. Applications must be mailed to the following address:
LSLBC
Attention: Applications Department
600 North Street
Baton Rouge, LA 70802
*We cannot accept applications by email or fax.
10. Note: Applicants are given one year from the date the application is received to meet all requirements. If
all requirements are not met within the one year timeframe, the application and fees will be written off and
the applicant will be required to submit a new application, documents, and fees.
Louisiana State Licensing Board for Contractors
600 North Street, Baton Rouge, LA 70802 225.765.2301 Fax: 888.510.0130
www.lacontractor.org
HOME IMPROVEMENT REGISTRATION APPLICATION
2
Section 1: IDENTIFYING INFORMATION
Name of Applicant
Once issued, applicants must conduct their contracting business under the exact name listed on the registration
If applying as a company put company name as name of applicant below. Note: The company name must also match
the business entity registered with LA Secretary of State
If applying as a sole proprietor (individual), put your individual name as the name of applicant below.
A. Full Legal Name of Applicant:
B. Type of Business:
☐
☐
Limited Partnership
☐
☐
Joint Venture
☐
☐
Limited Liability Partnership (LLP)
☐
Sole Proprietor (Individual)
C. If applying as a Sole Proprietor:
(required)
SSN:
Date of Birth:
D. If applying as a Business Entity:
(required)
Tax ID/FEIN:
Louisiana Secretary of State Charter Number:
E. Mailing Address of Principal Place of Business:
P.O. Box or Street Address
City, State, Zip Code
F. Physical Address of Principal Place of Business:
Street Name and Number
City, State, Zip Code
Phone
Cell
Fax
Email
Website
*An email address must be provided. Correspondence will be sent to this email address.
Louisiana State Licensing Board for Contractors
600 North Street, Baton Rouge, LA 70802 225.765.2301 Fax: 888.510.0130
www.lacontractor.org
HOME IMPROVEMENT REGISTRATION APPLICATION
3
Section 2: BUSINESS INFORMATION
Note: This section is not required for Sole Proprietors (i.e. those applying in their individual name).
Complete the appropriate section below based on the type of business:
Only complete the section that applies to your type of business
Dates of Births and Social Security Numbers are required for every officer, partner or member.
Type of
Business
Officers,
Partners or
Members
Full Name
Date of Birth
mm/dd/yyyy
Social Security
Number
Corporation
President
Vice President
Treasurer
Fiscal Officer
Partnership
Partners
LLC
Member(s)
Section 3: LEGAL INFORMATION
As used on this Application, the terms “you” and “your” shall mean the applicant, whether an individual or a corporation, partnership,
firm, joint venture, limited liability company or any other business or legal entity with which the applicant is or has been affiliated, or
principals of the applicant’s firm.
A.
☐ Yes
☐ No
Have you ever filed bankruptcy as an individual or under any firm name whatsoever in
Louisiana or in any other state (within the last ten years)?
If YES, provide copies of records showing the chapter filed, the initial debts submitted (including all creditors and the amount
remaining owed each), and a discharge summary. For bankruptcies discharged over ten years ago, send only a copy of the
discharge summary.
B.
☐ Yes
☐ No
Are there now any liens, judgements or attachments pending or recorded against you, or
against any firm in which you had interest at the time such indebtedness was created, or
against any property involved under any of your contracts arising out of your previous
operations in ANY state?
If YES, provide a certificate of release or a payment plan, along with a statement from the legal agency showing that the plan is
current.
C.
☐ Yes
☐ No
Have you or principals in your firm been convicted of a felony or a misdemeanor other
than a violation of traffic laws?
If YES, explain on separate sheet.
D.
☐ Yes
☐ No
Do you have an outstanding notice of child support delinquency which has not been resolved?
If YES, provide a copy of the agreement with the court along with a letter from the Louisiana Department of Children and
Family Services indicating that your child support payments are current.
Note: “Resolved” means you are now current with your child support payments or have entered into a payment plan, which is
also current.
4
Section 4: AFFIDAVIT
Instructions for Affidavit:
Applicant, Officer or Authorized Representative must read each statement below and initial next to each (required)
Applicant, Officer or Authorized Representative must print and sign name below and have signature notarized.
Initial:
1. I certify under penalty of perjury under the laws of the State of Louisiana that all statements, answers and
representations in this application, including all supplementary statements attached thereto, are true and
accurate to the best of my knowledge and belief and acknowledge that any purposeful false information
submitted on behalf of myself and/or this applicant and verified by this signature is cause to have
registration denied or revoked by the State Licensing Board for Contractors.
Initial:
2. I understand that the licensing board will use the mailing address and/or email address provided as official
means of communication. I also acknowledge and understand that I will monitor the email address provided
for official correspondence from LSLBC.
Initial:
3. I understand that any changes to my mailing address, physical address and/or email address must be
updated with LSLBC.
Initial:
4. I hereby agree to comply with all Contractor Licensing Laws (La. Revised Statutes 37:2150-2192) and
Contractor Rules and Regulations (Title 46 of the Professional and Occupations Standards) Part XXIX,
Contractors, Chapters 1 – 7. A copy of this document can be viewed and downloaded from our website
at: http://www.lslbc.louisiana.gov/wp-content/uploads/blue_book.pdf I understand that the Louisiana State
Licensing Board for Contractors may take action to issue fines and penalties, and/or suspend or revoke any
registration issued for violation of the laws and Rules and Regulations governing the licensing of contractors
in Louisiana.
Initial:
5. In accordance with La. R.S. 37:2175.2(C) and Rules and Regulations Sec. 105(B) for active home
improvement registrations, I hereby certify that I will maintain the statutorily required insurance coverages
for general liability and workers’ compensation without a lapse in coverage. In accordance with La. R.S.
37:2171.3, every home improvement contractor shall provide to every person with whom they contract
current insurance certificates evidencing the amount of liability insurance coverage maintained and proof of
workers’ compensation coverage. I understand that failure to maintain in force the insurance coverages while
any of the registrations are active may result in disciplinary action by the board.
Sworn before me, Notary Public, this day of _______________
_
20______ in _________________________,
Louisiana.
______________________________________________
Print Name of Applicant, Officer or Authorized
Representative
______________________________________________
Signature of Applicant, Officer or Authorized
Representative
(Signature must be notarized.)
_________________________________________________
Signature of Notary Public
_________________________________________________
Notary/Bar #
5
HOME IMPROVEMENT REGISTRATION
CHECKLIST
☐ Complete all sections of the application, signed by applicant, and notarized
☐ $75.00 Application Fee; check, money order or credit card is accepted (NO cash)
If paying by credit card, complete credit card section below and submit with application
If paying by check or money order, make payable to:
o Louisiana State Licensing Board for Contractors or LSLBC
☐ Registered with the Louisiana Secretary of State (if applying as a business entity)
Once registered, the Charter Number must be provided on the application
☐ Certificate(s) of General Liability and Workers’ Compensation Insurance; both are required by all applicants
Must be emailed from agent to insurance@lacontractor.org AFTER the application is submitted
See specific insurance requirements on LSLBC website on the FAQ page
**IMPORTANT **
ALL APPLICANTS---Be sure to include an email address on page 1 of the application. In the near future, LSLBC will
be sending letters, notifications, renewals, etc. electronically to the email addresses provided. Be sure to keep this
email address updated with LSLBC.
Payment by Credit Card:
Home Improvement Application fee:
$75.00
Credit Card Swipe fee:
$7.00
Total Application fees:
$82.00
Credit Card Information
Card Type: _____________________________________________________ (VISA, MasterCard, American Express, etc.)
Account Number: _______________________________________________________
Expiration Date: __________________________
Security Code: _________________________
Address of Cardholder:________________________________________________________________________________
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Home Improvement Registration Application Form

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Completed 4 March 2020

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