Fillable ADRE - Form LI-217 Request For Cert Of Licensure LI-217

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ADRE - Form LI-217 Request For Cert Of Licensure LI-217

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LI-217-LICENSE_CERTIFICATION_REQUEST 08.21.2017
Page 1 of 1
A
R
IZONA DEPARTMENT OF REAL ESTATE (ADRE)
Licensing Division
www.azre.gov
100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007
DOUGLAS A. DUCEY
GOVERNOR
JUDY L
OWE
COMMISSIONER
LICENSE CERTIFICATION REQUEST (FORM LI-217)
The Arizona Department of Real Estate (ADRE) will provide a Certification of Licensure based upon information contained within
ADRE Electronic records. Information older than seven (7) years is not available and will not be provided. Employment history is not
included in the Certification; limited employment history may be obtained from ADRE Public Database at www.azre.gov
.
PAYMENT INFORMATION
• Effective November 1, 2012 Fee: $3.00 for each Certification/$0.50 for each Postage.
• Acceptable Forms of Payment:
□ Check, Money Order: (Enclosed with completed form)
□ Visa, Mastercard, American Express, Discover: (Message Center)
SUBMIT COMPLETED FORM:
• By mail to: Arizona Department of Real Estate; 100 North 15th Avenue, Suite 201; Phoenix, AZ 85007.
• REQUEST CANNOT BE COMPLETED OVER THE COUNTER OR EXPEDITED. Please allow approximately 5-7 business days of receipt
for processing.
P
LEASE COMPLETE ALL INFORMATION REQUESTED.
Individual
Name:
License Number:
Date of Birth:
Email:
Phone Number
Mailing Address:
City:
State:
Zip:
Entity
License Number:
Mailing Address:
City:
State:
Zip:
Attached Document From Outside Agency
Agency Name:
Mail Directly to Outside Agency (No Copy to Licensee)
Mailing Address:
City:
State:
Zip:
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ADRE - Form LI-217 Request For Cert Of Licensure LI-217

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Completed 7 May 2020

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