Form Rc-L-200b - License Application (Limited Liability Company) Page 5

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3: P

ART

ERSONS

OMPLETE AND ATTACH ADDITIONAL

ART

S AS NECESSARY TO PROVIDE THE INFORMATION

FOR ALL OF THE

OLLOWING

ERSONS ON THE LICENSE

•

Owners of 25% or more of the stock or beneficial interest of the LLC.

•

If the Applicant is a Member-Managed LLC, then complete Part 3 for each Member.

•

If the Applicant is a Manager-Managed LLC, then complete Part 3 for each Manager.

This information is required under A.R.S. § 32-1122(B)(1)(d).

Every person listed on this application must be 18 years of age or older and must sign this application form

under

Part 6:

Signatures.

Arizona Corporation Commission Documents

To determine which individuals are members or managers of an LLC, refer to the LLC’s

entity documents. Entity documents can be located using the Corporation Commission’s

search tool

located at

•

Note:

This application is only for LLCs owned solely by individuals.

•

If any corporation, LLC, partnership, trust, or other business organization is listed

on the applying entity’s Arizona Corporation Commission documents, then you

must contact the Registrar’s Licensing Department at (602) 542-1525 for

assistance.

This application is for a:



Member-Managed LLC……………………………………………………………………………….



Manager-Managed LLC……………………………………………………………………………….

/ M

EMBER

ANAGER

The Registrar requires all of the information below for each member (if the applicant is a member-managed LLC) or each

manager (if the applicant is a manager-managed LLC).

1. Name as it appears on your government-Issued ID

2. Title/Position (“Member” or “Manager”)

3. Ownership %

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

5. Identification No. (Driver’s License or Government ID No.)

6. Social Security Number

7. Business or Residential Address

City

State

Zip Code

8. Mailing Address (If different than business or residential address)

City

State

Zip Code

9. Phone Number

10. Email Address

Email / Telephone

ONSENT

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

email address

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

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

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 3 of 8