Fillable Form 100: BROKER CANDIDATE EXPERIENCE VERIFICATION (FORM LI-226) (Arizona Department of Real Estate)

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Form 100: BROKER CANDIDATE EXPERIENCE VERIFICATION (FORM LI-226) (Arizona Department of Real Estate)

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ADRE Lic Form LI-226 Broker Can Exp Verif 8/2019
Page 1 of 1
ARIZONA
DEPARTMENT OF REAL ESTATE (ADRE)
Licensing
D
ivision
www.azre.gov
100
North 15th Avenue, Suite 201, Phoenix, Arizona 85007
'28*/$6$'8&(<
GOVERNOR
JUDY LO
WE
COMMISSIONER
BROKER CANDIDATE EXPERIENCE VERIFICATION (FORM LI-226)
Review Guidelines/Instructions BEFORE submitting this form.
CANDIDATE INFORMATION
Print Candidate Name as it appears on Real Estate License:
License Number:
Licensed State:
Expiration Date:
Current Mailing Address:
City:
State:
Zip:
Email Address:
Alternate Phone Number:
Job Title with current employer:
Start Date
Broker's Initials
*Must be initialed by Designated (Principal) Broker
CANDIDATE ATTESTATION
I affirm by my signature and initials below that my representations herein are true and have the actual experience stated.
Candidate Signature
X
Date
BROKER INFORMATION – To be completed by each Employing Broker and/or out of state Designated Broker(s).
Print Designated (Principal) Broker Name as it appears on Real Estate License:
License Number:
Licensed State:
Expiration Date:
Entity (Brokerage) Legal Name & DBA:
Entity License Number:
Expiration Date:
Entity (Brokerage) Current Mailing Address:
City:
State:
Zip:
Designated (Principal) Broker Email Address:
Phone Number:
Alternate Phone Number
:
Additional statement is attached.
DESIGNATED (PRINCIPAL) BR
OKER ATTESTATION
I affirm by my signature below that I am the Designated (Principal) Broker for the brokerage named above and that I/the brokerage
employed the Candidate named above within the past five (5) years, as indicated by the Start Date and End Date. To the best of my
knowledge and belief, the Candidate engaged in activities for the stated actual full time hours monthly, for which an active license was
required (check applicable license type below).
Real Estate Cemetery
Total
actual full time hours worked (monthly) Broker's Initials
Membership Camping
Designated (Principal) Broker Signature
X
Date
ADRE VERIFICATION
EXPERIENCE VERIFIED
YES NO
Authorized ADRE Signature
X
999 APPROVAL STAMP
DATE STAMP
PROCESS DATE
Broker's Initials
End Date
E-mail Address:
*
* *
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Form 100: BROKER CANDIDATE EXPERIENCE VERIFICATION (FORM LI-226) (Arizona Department of Real Estate)

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Completed 20 July 2020

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