Form Rc-L-200b - License Application (Limited Liability Company) Page 4

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2: Q

ART

UALIFYING

ARTY

UALIFYING

ARTY

The "Qualifying Party" is a person who is regularly employed by the Applicant and is actively engaged in the

classification of work for which the person qualifies on behalf of the Applicant.

•

The Qualifying Party must have the necessary experience, knowledge and skills to supervise or perform the

contracting work.

1. Name as it appears on your government issued ID

2. Title/Position

3. Ownership %

4. Date of Birth (MM/DD/YYYY)

5. Driver’s License or Government ID No.

6. Social Security Number

7. Residential Address

City

State

Zip Code

City

State

Zip Code

8. Mailing Address (If different than residential address)

9. Phone Number

10. Email Address

Email / Telephone

ONSENT

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

email address

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

12. 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

Page 2 of 8