Form Li-202 - Salesperson/associate Broker Change Form

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ARIZONA DEPARTMENT OF REAL ESTATE (ADRE)
GOVERNOR
Licensing Division
JUDY LOWE
th
COMMISSIONER
2910 N. 44
Street, Suite 100, Phoenix AZ 85018
SALESPERSON / ASSOCIATE BROKER CHANGE (FORM LI-202)
To be used only by Licensees with ADRE Departmental Matters
Salesperson or Associate Broker Information
Licensee Name (Print):
License Number:
Expiration Date:
Email Address:
Licensee Signature
Date
X
Provisional License or Departmental Matter?
Yes
No
Provisional License
Other Departmental Matter
Type of Change Being Made
HIRE
TRANSFER
SEVER
Licensee HIRE/TRANSFER Agent To
Hiring Entity Legal Name:
Hiring Entity License Number:
Hiring Entity DBA Name:
Physical Address (Branch):
Suite:
City:
State:
Zip Code:
County:
AZ
Phone:
Fax:
Hiring Designated Broker Name (Print):
Hiring DB License Number:
Hiring Designated Broker Signature
Date:
X
SEVER Agent From
Severing Entity Legal Name:
Severing Entity License Number:
Severing Designated Broker Name (Print):
Severing DB License Number:
Severing Designated Broker Signature
Date:
X
ADRE E&C USE ONLY
E&C SIGNATURE
DATE
ORDER
ADRE LICENSING USE ONLY
Effective Date
Date Stamp
Receipt
Input Date
Time Frame
TF-1
TF-2
Processed By
ADRE Lic Form LI-202 Salesperson-Broker Change rev 08 22 2013

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