STATE OF LOUISIANA DEPARTMENT OF EDUCATION STATE CENTRAL 2026

1. Click ‘Get Form’ to open the STATE CENTRAL REGISTRY DISCLOSURE FORM in the editor.
2. Begin by entering the 'Name of Licensed Facility' and its 'Physical Address'. Ensure accuracy as this information is crucial for identification.
3. Fill in the 'License#' associated with the facility, followed by your personal details: 'Name of Individual/Applicant', 'Date of Birth', and 'Social Security #'.
4. Provide any previous names used under 'Maiden, Previous or Any Other Name Used', along with your 'Race' and 'Sex'.
5. Complete your current address details including 'Current Street Address', 'City and State', and 'Zip Code'.
6. List your most recent previous address, ensuring to include all relevant city, state, and zip code information.
7. Input your current home phone number, cell phone number, and work phone number in the designated fields.
8. Indicate whether you have been recorded as a perpetrator on the State Central Registry by checking the appropriate box.
9. Review all entered information for accuracy before signing. Finally, provide your signature along with the date, and ensure that a representative from the licensed facility also signs.

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