Fillable BRANCH OFFICE APPLICATION/CHANGE (FORM LI-219) (Arizona Department of Real Estate)

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BRANCH OFFICE APPLICATION/CHANGE (FORM LI-219) (Arizona Department of Real Estate)

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ADRE Lic Form LI-219 Branch Off App rev 03.12.2013
Page 1 of 1
ARIZONA DEPARTMENT OF REAL ESTATE (ADRE)
Licensing Division
www.azre.gov
100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007
'28*/$6$'8&(<
GOVERNOR
J
UDY LOWE
COMMISSIONER
BRANCH OFFICE APPLICATION/CHANGE (FORM LI-219)
MAIN OFFICE INFORMATION:
Entity License Number:
Expiration Date:
Entity Legal Name:
EIN:
DBA Name:
Designated Broker (DB) Name
DB License Number:
Email:
Designated Broker (DB) Signature
X
Date:
TYPE OF REQUEST:
New Branch Office
ADRE ONLY – BRANCH #
Activate an Inactive Branch Office Close Branch Office
BRANCH OFFICE INFORMATION: (Must submit Form LI-204 to appoint branch manager)
This office is to be:
Closed
Active
Suite:
City:
State:
Zip:
County:
Branch Office Phone:
Branch Office Fax:
Branch Office Mailing Address: Same as Branch Physical Address:
Suite:
City:
State:
Zip:
County:
Print Branch Manager Name:
Branch Manager License Number:
Expiration Date:
Branch Manager Signature:
X
Date:
FOR ADRE USE ONLY
Effective Date
Date Stamp
Receipt
Input Date
Time Frame
TF-1
TF-2
Processed By
Arizona
Arizona
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BRANCH OFFICE APPLICATIONCHANGE (FORM LI-219) (Arizona Department of Real Estate)

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Completed 20 July 2020

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