Form Rc-L-200b - License Application (Limited Liability Company) Page 3

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For Internal Use Only

Form

ICENSE

PPLICATION

RC-L-200B

(LLC)

Pending #______________

1: A

ART

PPLICANT

NFORMATION

To avoid delay or denial, the Applicant must completely and accurately fill out the following information.

• An Authorized Representative is a person with the authority to sign on behalf of the LLC.

• The business address you provide will be publicly available on the Registrar’s website.

o To obtain a contractor’s license, an applicant must provide their mailing address and the address

or location of the applicant’s place of business if it is different from the applicant’s mailing

address. A.R.S. §§ 32-1122(B)(1)(b) & (f).

•

To determine the appropriate License Classification Description in box 6, refer to the Registrar’s

License

Classifications

located at https://roc.az.gov/license-classifications.

1. Limited Liability Company Name

2. Fictitious Trade Name (i.e. DBA), if applicable.

Warning: A licensee must do business under the name on the license issued. See A.A.C. R4-9-109(A). If you are

using a fictitious trade name (i.e. DBA), then the name of the LLC and the fictitious trade name must be included in

all contracts and advertisements.

3. Authorized Representative’s Name as it Appears on a Government-Issued ID

4. Authorized Representative’s Date of Birth (MM/DD/YYYY)

5. Authorized Representative’s Social Security Number

6. Requested License Classification Description

7. Federal Employer Identification Number (EIN)

8. Business Address (No PO Boxes or Private Mail Boxes)

City

State

Zip Code

9. Mailing Address (If different than business address)

City

State

Zip Code

10. Phone Number

11. Email Address

Email / Telephone

ONSENT

12. I consent to receive notifications from the Registrar by email at the following

email address

.....................................................................................................................................................................

13. I consent to receive notifications from the Registrar by text messaging at the

following telephone number

..................................................................................................................................

“Notifications” include renewal notices and monthly newsletters. By consenting to receive notifications via text or email, you

will not be excluded from receiving notifications by regular mail. You consent by entering the information above.

1700 W. Washington Street, Suite 105 ● Phoenix AZ 85007-2812

602.542.1525 ● Within AZ 877.692.9762 ● Fax 602.542.1599 ●

License Application (LLC)

Form RC-L-200B

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