LI-243 RENEWAL APPLICATION 8/2019 Page 1 of 1
Douglas A. Ducey
ARIZONA DEPARTMENT OF REAL ESTATE (ADRE)
100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007
RENEWAL APPLICATION (LI-243)
Licensee’s LEGAL Name if being renewed
Brokerage LEGAL Name if being renewed
ADRE ONLY – ACC FOR ALL ENTITIES
License number being renewed
Currently Expires On
Do you have a PC or a PLLC?
ADRE ONLY – ACC FOR ALL PC’S OR PLLC’S
If Yes, what is the PC or PLLC name?
Check type of renewal for this submittal. Mark all that apply.
Salesperson Assoc Broker Designated Broker Sole Proprietor Provisional
How many offices need to be renewed if renewing employing broker license?
Main Office Branch Office/s How many active branch offices need to be renewed? ___________________
Is this license currently? Mark all that apply.
ADRE E&C USE ONLY
E & C SIGNATURE DATE
Provisional Departmental Matter
If you are Active complete the following Entity (Brokerage) Information below.
Employing Entity(Brokerage) Legal Name
Employing Entity(Brokerage) DBA Name
Physical Business Address
CITY STATE COUNTY ZIP
DATE PRINT DESIGNATED BROKER NAME
(If Sole Proprietor, in signing this form, I declare I am the ONLY person who owns, has exclusive title or legal right to the business.)
For Department Use Only
TF 1 TF 2
“ADRE IS AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY” This form is available in alternate formats by contacting the Operations Office at 602-771-7760.