COVID-19 REQUIRED SCREENING - A1 Mobile Notary in Lake Charles LA

Date / Time of Appointment *

Date

Time

Location of Appointment *

Legal Name *

First

Last

Cell Phone Number *

Email *

Check any and ALL symptoms that YOU or ANY Of your FAMILY members have experienced within the LAST 14 DAYS.

Confirmation:

I confirm that the answer to ALL of the above symptoms or situations is NO.

I understand that if anyone at my appointment does not properly wear a mask (even if they are excluded from the state mandate) that my appointment will be cancelled and I will still owe a minimum $40 fee for the notary's travel.

Yes, I agree to pay the travel fee upon cancellation due to ANY reason.

Additional Comments

By Typing Your Name below, this is considered your electronic signature and your attestation to truthfulness to the answers in this screening. *