ADRE Lic Form LI-218 Lic Cancel rev 07.31.2013
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DEPARTMENT OF REAL ESTATE (ADRE)
100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007
DOUGLAS A. DUCEY
CANCEL LICENSE - VOLUNTARILY (FORM LI-218)
Form is completed by licensees to request a voluntary cancellation of licensure. Submit completed form and
attachments to the Department through the Department Message Center Click Here
Licensee Full Name (Please Print):
Please check the boxes to affirm the information stated.
I fully understand that I have the right to voluntarily cancel my license per A.R.S. §32-2137.
I fully understand that, should I want to reinstate my license, I must comply with the requirements stated
in A.R.S. §32-2131.
I understand that I am not presently under investigation by the Department.
The Department has not commenced any disciplinary proceedings against my license.
*Broker information and signature only required for active real estate licensees
Print Employing Broker Name:
Designated Broker Signature:
ADRE will handle inactivation process
Approved (Subject to Commissioner’s Approval)