Fillable Li-214/244 Disciplinary Actions Disclosure printable pdf download

Arizona Department of Real Estate (ADRE)

GOVERNOR

Licensing Division

JUDY LOWE

COMMISSIONER

2910 N. 44

STREET ● SUITE 100 ● PHOENIX, AZ ● 85018

DISCIPLINARY ACTIONS DISCLOSURE (LI-214/244)

ARS §§ 32-2123 and 32-2130 & AAC R4-28-301 and AAC R4-28-303

The Disciplinary Actions Disclosure is required by ADRE to determine qualifications and suitability of the licensee to hold an Arizona Real Estate

License, Employing Broker License, Entity License, Cemetery License or a Membership Camping License, Educational School License, Educational

Instructor License or Public Report License. Check one:

Original Application. Disciplinary Actions Disclosure for Misdemeanors (immediate past 10 years); Felony-indefinitely



Renewal Application. Disciplinary Actions Disclosure for immediate past renewal period.



Failure to answer these questions truthfully may result in disciplinary actions including, but not limited to, suspension, revocation and/or civil penalties

ARS §§ 32-2153(B) and 32-2160.01

Has the Applicant / Is the Applicant:

Had a professional or occupational license or registration of ANY kind denied, suspended, restricted, or revoked? (Drivers

 YES

 NO



License/CDL not included)

Had an administrative order and/or ANY other disciplinary action taken against ANY license issued to them by any local,

 YES

 NO



state, or federal regulatory agency?

Had an action issued by the ADRE which resulted in an Accelerated Settlement Agreement (ASA)?

 YES

 NO



Voluntarily surrendered ANY professional or occupational license during the course of an investigation or disciplinary

 YES

 NO



proceeding?

Entered into ANY consent decree, and/or had an injunction (either temporary or permanent), a suspension, an order

 YES

 NO



and/or a judgment issued which prohibited or restricted them from engaging in ANY profession or occupation?

Had any judgment and/or order against them by ANY court involving fraud, dishonesty, misrepresentation, unfair trade

 YES

 NO



practice, or moral turpitude?

Had any judgment and/or order entered against them by ANY court arising out of the conduct of any business in real

 YES

 NO



estate, cemetery property, timeshare intervals, or membership campgrounds?

Had ANY SUBDIVISION PUBLIC REPORT or REGISTRATION TO SELL real estate, timeshares, cemetery lots, or

 YES

 NO



campground memberships denied and/or suspended?

Had ANY payment made from the real estate recovery fund and/or ANY similar fund that was charged against them

 YES

 NO



and/or against a business for which they were the qualifying party?

Currently involved in ANY pending disciplinary hearings and/or other administrative actions, against ANY professional

 YES

 NO



and/or occupational licenses held in Arizona and/or in any other state?

Held, and/or currently holds ownership and/or controlling interest of 10% or more in any business, corporation,

 YES

 NO



partnership, or limited liability company that would cause them to answer “yes” to any of the above questions.

Been convicted and/or entered into a plea agreement and/or a plea of NOLO CONTENDERE (no contest) to ANY felony in

Arizona and/or any other state, whether or not the plea or verdict was set aside, judgment or sentencing was deferred,

 YES

 NO



conviction was dismissed or expunged, or has been pardoned?

Been convicted or entered into a plea agreement or a plea of NOLO CONTENDERE (no contest) to ANY misdemeanor in

Arizona or any other state, whether or not the plea or verdict was set aside, judgment or sentencing was deferred, the

 YES

 NO

conviction was dismissed or expunged, or has been pardoned?



CONVICTIONS – DUI AND/OR RECKLESS DRIVING, EITHER MISDEMEANOR OR FELONY, MUST BE DISCLOSED

Minor traffic citations do not constitute a misdemeanor or felony offense.

CURRENTLY in a deferred period of judgment or sentencing, in a diversion program, and/or convicted of a Class 6

 YES

 NO



Undesignated Offense, which has not yet been designated as a felony or misdemeanor as of the date of this application?

CURRENTLY incarcerated, paroled, and/or on probation because of ANY conviction?

 YES

 NO



If the applicant answered YES to any questions 1 through 14, applicant must also answer the following:

Has the applicant previously disclosed the incident to ADRE in writing?

 YES

 NO



Approximate date of disclosure

Type of disclosure

If the incident and/or action has not previously been disclosed to the ADRE in writing, refer to the DISCLOSURE DOCUMENT CHECKLIST FORM

(LI-400) for a list of additional required documentation that must be submitted to ADRE before a renewal application is submitted for processing.

A fingerprint clearance card is required if there are any “YES” answers, other than a “YES” on question number 3.

ATTESTATION

I attest, under penalty of perjury, under the laws of the State of Arizona, that the foregoing answers and statements given in this application are

true and correct. I certify that at the time of ADRE license issuance, I will be 18 years of age or older. I certify that while licensed, I will not violate

any provisions of Real Estate Laws nor abuse the privileges of ADRE issued licenses.

Print Name

Signature of Applicant

Date

ADRE License#

Email Address

LI-214/244 Rev 4/2012