Fillable LICENSE CERTIFICATION REQUEST (FORM LI-217) (Arizona Department of Real Estate)

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LICENSE CERTIFICATION REQUEST (FORM LI-217) (Arizona Department of Real Estate)

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LI-217-LICENSE_CERTIFICATION_REQUEST 11.18.2019
Page 1 of 1
A
R
IZONA DEPARTMENT OF REAL ESTATE (ADRE)
Licensing Division
www.azre.gov
100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007
DOUGLAS A. DUCEY
GOVERNOR
JUDY L
OWE
COMMISSIONER
LICENSE CERTIFICATION REQUEST (FORM LI-217)
The Arizona Department of Real Estate (ADRE) will provide a Certification of Licensure based upon information contained within
ADRE Electronic records. Information older than seven (7) years is not available and will not be provided. Employment history is not
included in the Certification; limited employment history may be obtained from ADRE Public Database at www.azre.gov
.
PAYMENT INFORMATION
• Fee: $3.00 for each Certification/$0.50 for each Postage.
• Acceptable Forms of Payment:
□ Check, Money Order: (Enclose with completed form)
□ Visa, Mastercard, American Express, and Discover are accepted. Do not provide credit card numbers through the Message Center.
A payment request will be sent to you after this form is received.
SUBMIT COMPLETED FORM:
• By mail to: Arizona Department of Real Estate; 100 N. 15th Ave., Suite 201; Phoenix, AZ 85007.
• REQUEST CANNOT BE EXPEDITED. Please allow
approximately 5-7 business days of receipt for mailing. The most expeditious
way to request a license certification is through the Message Center.
P
LEASE COMPLETE ALL INFORMATION REQUESTED.
Individual
Name:
License Number:
Date of Birth:
Email:
Phone Number
Mailing Address:
City:
State:
Zip:
Entity
License Number:
Mailing Address:
City:
State:
Zip:
Attached Document From Outside Agency
Agency Name:
Mail Directly to Outside Agency (No Copy to Licensee)
Mailing Address:
City:
State:
Zip:
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LICENSE CERTIFICATION REQUEST (FORM LI-217) (Arizona Department of Real Estate)

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Completed 20 July 2020

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