Fillable ADRE - Form LI-227 App For Temp Cemetery Lic Or Camp Cert

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ADRE - Form LI-227 App For Temp Cemetery Lic Or Camp Cert

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ADRE Lic Form LI-227 Inst-Checklist rev 8/2019
Page 1 of 1
AR
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
LOWE
COMMISSIONER
CEMETERY SALESPERSON TEMPORARY LICENSE OR
MEMBERSHIP CAMPGROUND CERTIFICATE OF CONVENIENCE (FORM LI-227)
CHECKLIST/INSTRUCTIONS
Submit completed Form LI-227 (Cemetery Salesperson Temporary License or Membership Campground
Certificate of Convenience Application).
Submit completed Form LI-214/244 (Disciplinary Actions Disclosure). If you answer “YES” to any of the
questions, provide documents listed on Form LI-400 (Disclosure Document Checklist Form).
Fingerprint Clearance Card Submitted
Fingerprint Clearance Card Applied For (Date) _______________________________________________
Temporary Cemetery Salesperson Fees
License $50.00
ADRE Recovery Fund $10.00
Total $60.00
Campground Salesperson Fees
License $50.00
Total $50.00
Application must be complete when submitted to ADRE or application will be returned
unprocessed.
Temporary License provided herein shall expire:
• Cemetery: at ninety (90) days from issuance. Only one (1) temporary license will be granted.
• Membership Campground: at thirty (30) days from issuance. Only one (1) temporary license will be
granted.
To Submit: visit Message Center at www.azre.gov
ADRE Lic Form LI-227 rev 08.20.2012
Page 1 of 1
ARIZONA DEPARTMENT OF REAL ESTATE (ADR
E)
Licensing Division
www.azre.gov
100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007
DOUGLAS A. DUCEY
GOVERNOR
JUDY
LOWE
COMMISSIONER
CEMETERY SALESPERSON TEMPORARY LICENSE OR
MEMBERSHIP CAMPGROUND CERTIFICATE OF CONVENIENCE (FORM LI-227)
Review instructions and checklist before filing this form.
Select Type of Application:
Cemetary Salesperson Temp Application Membership Campground CC Application
Legal Name
Date of Birth
Social Security Number
Residence Address
City
State
Zip
Mailing Address Same as Residence Address
City
State
Zip
Email
Fingerprint Clearance Card Attached Fingerprint Clearance Card Applied For Date: ________________________________________
Applicant’s Signature
X
Company Name
Entity License No.
Business Address
Suite
City
State
Zip
Phone
Fax
Email
DB Name
DB License No.
Expiration Date
DESIGNATED BROKER ATTESTATION
STATE OF ARIZONA )
COUNTY OF ___________________________ )
I, the undersigned employing cemetery / campground broker of _________________________________________________________________
(Name of Licensed Entity)
Being duly sworn upon oath, deposes and say that ____________________________________________________________________________
(Name of cemetery / camping salesperson)
Is trained in applicable Arizona cemetery and contract law pursuant to A.R.S. § 32-2134; A.C.C. R4-28-305(B) OR
Will be trained in applicable Arizona membership camping and contract law pursuant to A.R.S. § 32-2134.01; A.C.C. R4-28-305
Dated this _________ day of ___________________________ Year _____________
Signature of Designated Broker/Sole Proprietor: X _______________________________________
Subscribed and Sworn to before me this ___________ day of _____________ year _____________
_____________________________________________ My Commission expires: _________________
(Notary Public)
FOR ADRE USE ONLY
Effective Date
Date Stamp
Receipt
Input Date
Time Frame
TF-1
TF-2
Processed By
Notary Seal
AZ
AZ
AZ
Notice to Applicant Pursuant to A.R.S. § 41-1030
An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically
authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for
imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically
authorizes the requirement or condition.
This section may be enforced in a private civil action and relief may be awarded against the State. The court may award
reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action
against the state for a violation of this section.
A State employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action
or dismissal pursuant to the Agency's adopted personnel policy.
This section does not abrogate the immunity provided by section 12-820.01 or 12-
820.02
Notice to Applicant Pursuant to A.R.S. § 41-1093.01
An agency shall lim
it all occupational regulations to regulations that are demonstrated to be necessary to specifically fulfill a
public health, safety or welfare concern. Pursuant to sections 41-1093.02 and 41-1093.03, Arizona Revised statutes, you have
the right to petition this agency to repeal or modify the occupational regulation or bring an action in a court of general jurisdiction
to challenge the occupational regulation and to ensure compliance with section 41-1093.01, Arizona Revised Statutes.
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ADRE - Form LI-227 App For Temp Cemetery Lic Or Camp Cert

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Completed 7 May 2020

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