STATE OF ARIZONA
DEPARTMENT OF HOUSING
1110 WEST
WASHINGTON,
SUITE
28
0
PHOENIX, ARIZONA 85007
(602) 771-1000
(602) 771-1002 FAX
CHANGE OF
EMPLOYING
DEALER
Name of Salesperson
Salesperson’s License Number
Name of New Employing Dealer
L
icense Number of New Employing Dealer
Effective Date of Change to New Dealer
Salespersons Signature Signature of Qualifying Party of New
Employing Dealer
THIS FORM MUST BE SUBMITTED WITH THE $10.00 ADMINISTRATIVE FUNCTION FEE.
MAKE CHECK PAYABLE TO THE ARIZONA DEPARTMENT OF HOUSING.
MAIL COMPLETED FORM AND CHECK TO:
ARIZONA DEPARTMENT OF HOUSING
P.O. BOX 6280
PHOENIX, AZ 85005-6280