Fillable NEW QUALIFYING PARTY INSTRUCTIONS AND REQUIREMENTS Each business (Arizona)

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NEW QUALIFYING PARTY INSTRUCTIONS AND REQUIREMENTS Each business (Arizona)

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NEW QUALIFYING PARTY INSTRUCTIONS AND REQUIREMENTS
Each business license shall have one Qualifying Party. “Qualifying Party” means a person who is an
owner, employee, corporate officer, member or partner of the licensed business and who has active and
direct supervision of and responsibility for all operations of that licensed business. The Qualifying Party
shall ensure full compliance with all provisions of the Act in regulating the business of the licensee under
Title 41, Chapter 37, Articles 3 and 4, of the Arizona Revised Statutes, and the Rules and Regulations of
the Department of Housing (“Department”).
The Qualifying Party is required to reside within the State of the principal place of the licensee's business,
as listed on the license application, and shall not act in the capacity of qualifying party for more than one
license in the same classification.
It is the licensee's responsibility to notify the Department within five (5) business days of the
disassociation of a qualifying party, including the name of the person who will be temporarily responsible
for the operation of the business.
The following items must be submitted to the Department:
1. Resignation letter from previous Qualifying Party (“QP”) that states the date he or she ceased to be the
Qualifying Party for the license OR a letter, signed by a person who is listed under Section D of the
Application for License, that states the date the previous Qualifying Party ceased to be the Qualifying
Party for the license and that states the name of the person who will be the new Qualifying Party for the
license.
2. Certificate of New Qualifying Party
3. Statement of Authorization and Release of Information
4. Fingerprint card and $22.00 fingerprint processing fee in the form of certified funds payable to the
Arizona Department of Housing. Personal or company checks will not be accepted for the fingerprint
processing fee. *We will waive this requirement, if you provide us with a copy of the front and back of
your current Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety.
5. Arizona Statement of Citizenship and Alien Status for State Public Benefits (pages 1 and 2) and provide
acceptable evidence of U.S. citizenship or, if not a U.S. citizen, acceptable evidence of the right to live
and work in the U.S. Acceptable evidence is outlined in 'Evidence of Citizenship or of the Right to Live
and Work in the U.S.' that is posted on our website. If you are a U.S. citizen, the most common form of
proof of this is a copy of your current U.S. passport or passport card.
6. Required Notice from F.B.I.
7. Successful completion of the appropriate online dealer or installer license classification test with a score
of 80% or better. Manufacturers do not have a testing requirement. New Qualifying Party will be
registered to take the appropriate Department online test after that individual has provided with the
Department with items 1 through 6 listed above. All study materials are the responsibility of the
examinee. Dealer/Broker/Retailer examinations will consist of general knowledge of the Arizona
Revised Statutes and Rules of the Department of Housing. Links to the Statutes and Rules can be found
at our website, https://housing.az.gov/manufactured-housing. No test questions come from the “New
Dealer Handbook”. Installers will need a general knowledge of the current adopted codes we have listed
at our website of https:/housing.az.gov/manufactured-housing. Code books may be available at local
libraries, the local city or county building departments or book stores. We do not provide code books.
Page 2 of 2
8. The new Qualifying Party for an installer license shall:
a. Have a minimum of 3 years practical or field management experience in the specific type of
installation, a related construction field, or the equivalent, for which the applicant is applying. At least 2
of the 3 years experience shall be within 10 years of the date of the application. The applicant may
substitute technical training in the specific type of installation, a related construction field, or the
equivalent, from an accredited college or university or from a Department of Housing workshop for no
more than 1 year of the 3 years experience required. Certification Experience Verification forms must be
completed by past or present employers and submitted to the Department.
b. Supply a certified copy of each official transcript or certificate, demonstrating successful
completion of any technical training the applicant wishes the Department to consider as proof of meeting
the experience requirement.
The Qualifying Party for an installer license must obtain 3 educational credits each year in order to renew
the installer license. A list of the dates and times of training sessions can be found at our website.
ADOH 151 (3-19)
ARIZONA RELAY SERVICE FOR TTY USERS: TDD: 1-800-367-8939
DEPARTMENT OF HOUSING
1110 WEST
WASHINGTON,
SUITE
280
PHOENIX, ARIZONA
85007
(602) 771-1000
WWW.AZHOUSING.GOV
FAX: (602) 771-1002
CERTIFICATE OF QUALIFYING PARTY
PLEASE TYPE OR PRINT:
FULL NAME:
(DATE OF BIRTH)
ADDRESS:
(RESIDENCE ADDRESS)
(CITY, STATE, ZIP CODE) (PHONE NUMBER)
BUSINESS
NAME:
CLASSIFICATION:
I HEREBY CERTIFY THAT I have been appointed to act as the
QUALIFYING
PARTY for the above-named
license issued by the Department of Housing as
QUALIFYING
PARTY. I am a bona fide owner, corporate officer,
member, partner; employee (underline one) of the above-named license. I assume full
responsibility
for compliance
with the provisions of Arizona Revised Statutes, Title 41, Chapter 37, Articles 3 and 4, and the Rules and Regulations
adopted pursuant thereto by the Department of Housing. If for any reason I become disassociated or cease to be the
QUALIFYING
PARTY for the above mentioned licensee, I will within (5) days notify the
Department
of Housing in
writing.
1. Are you
presently
acting or have you previously acted on a license in the capacity of Yes No 
Qualifying Party in this or any other State?
2. Have you had a license refused or revoked within the past twelve months? Yes No 
3. Have you been convicted of a felony in any state or federal jurisdiction or Yes No 
have you ever had a final judgement brought against you in a civil action
on grounds of fraud,
misrepresentation,
or deceit?
NOTE: A yes answer to any of the above requires you to provide details.
I HEREBY CERTIFY under penalty of perjury that the foregoing is true and correct, and vouch for the truth and
accuracy
of all
supplementary
statements, answers and
representations
attached hereto and made a part of this
application.
SIGNATURE:
STATE OF
(Qualifying Party)
)
COUNTY OF
)
The foregoing instrument was acknowledged before me this day of , 20
My
Commission
expires
Notary
Public
DEPARTMENT OF HOUSING
1110 WEST
WASHINGTON,
SUITE
280
PHOENIX, ARIZONA
85007
(602) 771-1000 WWW.AZHOUSING.GOV
FAX: (602)-771-1002
STATEMENT
OF
AUTHORIZATION
AND RELEASE OF
INFORMATION
Your Full Name: Date of Birth:
Compl
ete Residence Address:
Residence Telephone:
Busine
ss Name Stated on License Application:
Position/Title You Hold:
(Example: president, managing member, qualifying party, partner, etc.)
I,
Your Full Name
, do hereby consent to having an inquiry made as to
my moral character, professional reputation and fitness for said license.
I also authorize and request every person, firm, company, corporation, governmental agency, court,
association or institution having control of any documents, records, and other information pertaining to
me, to furnish to the Department of Housing any such information, including documents, records, or
information regarding charges or complaints filed against me, formal or informal, pending or closed, or
any other pertinent data, and to permit the Department of Housing or any of its agents or representatives
to inspect and make copies of such documents, records and other information.
I hereby release, discharge and exonerate the Department of Housing, its agents and representatives and
any person so furnishing information from any and all liability of every nature and kind arising out of
the furnishing or inspection of such documents, records and other information of the inquiry made by the
Department of Housing.
State of )
County
of
)
Sig
nature: Date:
Printed
Name:
The foregoing instrument was acknowledged before me this day of , 20 .
Nota
ry Public Signature: My commission expires:
ADOH 103 (8-17)
Form
1:
LONG FORM
APPLICANT STATEMENT
(revised)
REQUIRING SUBMISSION
OF
DOCUMENTATION
OF STATUS
ARIZONA STATEMENT OF CITIZENSHIP
AND ALIEN STATUS FOR STATE PUBLIC BENEFITS
Professional License and Commercial License Department of Housing
Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8
U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen
nationals, non-exempt "qualified aliens" (and sometimes only particular categories of qualified aliens),
nonimmigrants, and certain aliens paroled into the United States are eligible to receive state or local public benefits.
With certain exceptions, a professional license and commercial license issued by a State agency is a State public
benefit.
Arizona Revised Statutes § 1-501 requires, in general, that a person applying for a license must submit
documentation to the licensing agency that satisfactorily demonstrates that the applicant is lawfully present in the
United States.
Directions: All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or
nationals must also complete Section III. Submit this completed form and copy of one or more documents
that evidence your citizenship or alien status with your application for license or renewal.
SECTION I — APPLICANT INFORMATION
APPLICANT’S
NAME
(Print
or
type)
DATE
TYPE OF
APPLICATION
(check one) INITIAL APPLICATION RENEWAL
TYPE
OF
LICENSE
SECTION II — CITIZENSHIP OR NATIONAL STATUS DECLARATION
Directions: Attach a legible copy of the front, and the back (if any), of a document from the attached List A or
other
document
that
demonstrates
U.S.
citizenship
or
nationality.
Name
of
document
provided:
A. Are you a citizen or national of the United States? (Check one) Yes No
B. If
the answer is “Yes,” where were you born? List city, state (or equivalent), and country.
City
State
(or
equivalent)
Country
or
Territory
If you are a citizen or national of the United States, go to Section IV. If you are not a citizen or national of the
United States, please complete Sections III and IV.
SECTION III — ALIEN STATUS DECLARATION
Directions: To be completed by applicants who are not citizens or nationals of the United States. Please indicate
alien status by checking the appropriate box. Attach a legible copy of the front, and the back (if any), of a document
from the attached List B or other document that evidences your status. A.R.S. § 1-501. Name of document provided:
.
“Qualified Alien” Status (8 U.S.C. §§ 1621(a)(1), -1641(b) and (c))
Q 1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA).
Q 2. An alien who is granted asylum under Section 208 of the INA.
Page 1 of 2
Rev (8-17) 81662 Page 2 of 2
Q 3. A refugee admitted to the United States under Section 207 of the INA
Q 4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA.
Q 5. An alien whose deportation is being withheld under Section 243(h) of the INA.
Q 6. An alien granted conditional entry under Section 203(a) (7) of the INA as in effect prior to April 1, 1980.
Q 7. An alien who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education
Assistance Act of 1980).
Q 8. An alien who is, or whose child or child’s parent is a “battered alien” or an alien subjected to extreme
cruelty in the United States.
Nonimmigrant
Status (8 U.S.C. § 1621(a) (2))
Q 9. A nonimmigrant under the Immigration and Nationality Act [8 U.S.C. § 1101 et seq.] Nonimmigrants
are persons who have
temporary
status for a specific purpose. See 8 U.S.C. § 1101(a) (15).
Alien Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a) (3))
Q 10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA
Other Persons (8 U.S.C. § 1621(c) (2)(A) and (C))
□ 11. A nonimmigrant whose visa for entry is related to employment in the United States, or
□ 12. A citizen of a freely associated state, if section 141 of the applicable compact of free association
approved in Public Law 99-239 or 99-658 (or a successor provision) is in effect [Freely Associated States
include the Republic of the Marshall Islands, Republic of Palau and the Federate States of Micronesia, 48
U.S.C. § 1901 et seq.];
□ 13. A foreign national not
physically
present in the United States.
Otherwise Lawfully Present (A.R.S. § 1-501)
□ 14. A person not described in categories 1–13 who is otherwise lawfully present in the United States.
PLEASE NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act
may make persons who fall into this category ineligible for licensure. See 8 U.S.C. § 1621(a).
SECTION IV — DECLARATION
All applicants must complete this section. I declare under penalty of perjury under the laws of the state of Arizona
that the answers I have given are true and correct to the best of my knowledge.
APPLICANT’S SIGNATURE TODAY’S DATE
Attachment: Lists A and B Evidence of U.S. Citizenship, U.S National Status, or Alien Status
FINGERPRINTING REQUIREMENTS
Fingerprint card(s) must be completed as outlined below and returned to the Department of Housing.
NOTE: The Fingerprint card requirement and fingerprint processing fee will be waived if you furnish the
Department with a copy of the front and back of your current Level One Fingerprint Clearance Card
issued by the Arizona Department of Public Safety.
A. One set of fingerprints and fee are required for:
1. The Qualifying Party; and
2. The Individual named as Sole
Proprietor (or Owner), or
3. Each Partner of a Partnership, or
4. The President, V.P., Secretary and Treasurer of a Corporation, or
5. The Managing Members of a Limited Liability Company, or
6. Each General Partner of a Limited Partnership, or
7. Any person applying for a Salesperson's license
B. Fees
1.
2.
A $22.00 fingerprint processing fee made payable to the Arizona Department of Housing
shall accompany each returned fingerprint card.
The fee shall be paid by cashier's check, money order, or other certified funds.
3. NO PERSONAL CHECKS OR COMPANY CHECKS will be accepted.
C. Where to be fingerprinted
The fingerprint card(s) may be taken to the nearest law enforcement agency - police department or
sheriff's office - at which time you will complete the necessary information and sign the card in the
designated space. In addition to the fingerprint processing fee, the agency taking the fingerprints
will also charge a fee which will vary according to their requirements.
D. What you must take to the official/person taking your fingerprints:
1. Unexpired photo identification
2. Fingerprint Verification Form
3. Mailing envelope for fingerprint card (usually 9x12 or larger)
*The Fingerprint Verification Form contains instructions and a section which must be filled
out
by the fingerprint technician. The instructions tell the fingerprint technician to request a valid,
unexpired
government-issued photo ID and to compare the physical descriptors on the photo ID
to the applicant. Once the applicant has been fingerprinted, the instructions tell the fingerprint
technician to place the fingerprint card and the completed Fingerprint Verification Form into
the envelope and seal it before returning the envelope to the applicant. The applicant then must
mail/deliver the envelope with the seal intact to the Department.
Page 1 of 3
FINGERPRINTING REQUIREMENTS
E. All information must be typed or printed in black. Each block to be completed is given a number
and the corresponding number description is outlined below.
1. Full name in all capital letters. If you only have a middle initial, designate (I.O.) (initial
only) next to the middle initial; if you do not have a middle name or initial, designate
NMI (no middle initial).
Last Name First Name Middle
Name
DOE JOHN
JOSEPH
2. Signature of individual being fingerprinted.
3. Complete residence address of the individual being fingerprinted, including apartment
number, city, state and ZIP code.
4. Aliases: Other names that may have been used at any time.
5. Date of birth in numbers, such as 7-21-52.
6. Citizenship: The name of the country you are a citizen of: U.S.A. or other citizenship.
7. - 12. Personal description, abbreviated:
Sex Race Hgt. Wgt. Eyes
Hair
M W 5'8" 165 BRN
BRN
13. Place of Birth: State City and State.
14. Armed Forces number: Military enlistment number even if it is your social security
number.
15. Social security number: Fill in the number even if it’s shown in Block 14.
16. Miscellaneous number: List any other identifying number.
17. Date and signature of official taking the fingerprints.
F. Taking of fingerprints. The following information must be followed exactly or the FBI
will reject the fingerprint card. You may wish to provide these instructions to the
fingerprint technician.
1. Have fingerprint technician make certain all impressions are taken in proper order,
legible, fully rolled nail to nail and classifiable. All data called for is essential.
2. If an amputation or deformity makes it impossible to print a finger, the fingerprint official
should make a notation to that effect, (i.e. “amp”) in the individual finger block. No other
writing is permitted in the fingerprint blocks.
3. If some physical condition makes it impossible to obtain perfect impressions, submit the
best that can be obtained. Make sure the fingerprint official does NOT stamp “best prints
possible” on card.
4. No highlighter can be used on the fingerprint blocks.
Page 2 of 3
FINGERPRINTING REQUIREMENTS
5. If the fingerprint image bleeds onto the blue lines or overlaps the borders of that block,
the card will be rejected.
6. Fingerprints at the bottom of the page must be straight up and down on the card.
G. Return of fingerprint card
1. WARNING: The fingerprint card(s) cannot be folded or defaced in any manner because
they are machine-processed.
2. Card must be returned in 9x12 (or larger) mailing envelope that was sealed by the
fingerprint technician. The fingerprint technician may not give the applicant the card
without first sealing it inside the envelope.
3. The fingerprint card(s) and fee(s) must be returned to the Department of Housing. The
background investigation must be completed before permanent status can be granted to
any conditional license that is issued.
H. All FBI record searches will be treated as confidential information and will not be disclosed,
except as provided by law.
Rev (8-17)
Page 3 of 3
FINGERPRINT VERIFICATION FORM
ATTENTION FINGERPRINT TECHNICIAN:
Please follow the instructions below for fingerprinting this applicant.
1. Please fill out or ensure that the applicant has filled out all the required boxes on the
fingerprint card prior to taking the fingerprints.
2. Request a valid, unexpired government-issued photo ID from the applicant and
compare the physical descriptors on the applicant’s photo ID to the applicant and to
the information on the fingerprint card.
3. Fill out the information in the boxes below. Please print clearly.
4. Once the prints have been taken, place the fingerprint card and this form into the
envelope provided by the applicant and seal it. Please write your name or
identification across the edge of the seal. Return the sealed envelope to the
applicant. Do not give the applicant the card without first sealing it inside the
envelope.
PRINT the following information:
Date Fingerprints Taken
Name of Applicant Fingerprinted
Fingerprint Technician’s Agency/Company Name
Type of Photo ID provided by applicant (check one)
Driver’s License/MVD issued ID Other (please specify on line below)
Passport
DEPARTMENT OF HOUSING
1110 WEST
WASHINGTON,
SUITE
28
0
PHOENIX, ARIZONA
85007
(602)
364-1003
WWW.AZHOUSING.GOV FAX: (602) 771-1002
Due to new Federal regulations, the Department of Housing is required to provide you with the following
Important Notice and required to maintain evidence in our files that we have done so before we may submit
your fingerprint card to the proper authorities for a background analysis.
Please complete this form and return it to the Department within five (5) business days. Thank you. _
IMPORTANT
NOTICE:
Your fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (“FBI”). If you have a criminal history
record, the officials making a determination of your suitability for the job, license, or other benefit must provide you the opportunity
to
c
o
m
p
lete or challenge the accuracy of the information in the record. You should be afforded a reasonable amount of time to correct
or
c
o
m
p
lete
the record (or decline to do so) before officials deny you the job, license, or other benefit based on information in the criminal history record.
The procedures for obtaining a change, correction, or updating of your FBI criminal history record are set forth in Title 28, Code of Federal
Regulations (CFR), Section 16.30 through 16.34. Information on how to review and challenge your FBI criminal history record can be found at
www.fbi.gov under Criminal History Summary Checks or by calling (304) 625-3878.
To obtain a copy of your Arizona criminal history in order to review/update/correct the record (if applicable), you can contact the Arizona Department
of Public Safety (“DPS”) Criminal History Records Unit at (602) 223-2222 to obtain a fingerprint card and a Review and Challenge packet. Information
on the review and challenge process can be found on the DPS website (www.dps.gov).
Your
S
ignatu
r
e
Your Printed
Na
me
State of ) Dated this day of , 20
C
ounty of
)
On this day of , 20 , before me personally appeared ,
whose identity was proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that
he/she executed the same.
Commission
E
xpires:
No
tary Public
Certification Experience Verification
Department of Housing
1110 W. Washington, Ste. 280, Phoenix, AZ 85007
Phone: 602-771-1000 Fax: 602-771-1002
STEP 1 APPLICANT INFORMATION (please print)
Name of Applicant:
Address:
City: State: Zip:
Phone: Fax: Email:
Verification of experience is required for installer applicants. This application to the Department of Housing is for
certification as an: I-10C I-10D I-10G (Check one.)
STEP 2 VERIFIER INFORMATION
Name of verifier:
Address:
City: State: Zip:
Phone: Fax: Email:
STEP 3 VERIFIED EXPERIENCE
Describe your knowledge of the applicant’s experience. Fill in the name of employer and dates of employment.
Describe applicant’s position and type of work performed. Describe the types of buildings, structures, or projects on
which the applicant worked. Give any other details that will aid in evaluating experience. Additional pages may be
attached.
I certify that I know the applicant and have direct knowledge that the applicant was employed from
to as a:
Month/Year Month/Year
Applicant’s position/title:
Company name:
Duties and responsibilities:
How was your knowledge of the applicant’s experience acquired?
I certify that the foregoing statements are true and correct.
Signature of verifier: Date:
The foregoing instrument was acknowledged before me this day of _, 20 . (NOTARY SEAL)
My commission expires Notary Public Signature
IRC
CHAPTER 1
R101 – R114
CHAPTER 2
R201 – R202
CHAPTER 3
R301
R309
R311
R314
R317 – R318
R320
R322
CHAPTER 4
R401 – R408
CHAPTER 5
R501
R506
CHAPTER 6
R606
R611
IBC
CHAPTER 1
101 – 116
CHAPTER 2
210 – 202
CHAPTER 3
301 – 302
BREEZE THRU
303 – 312
CHAPTER 5
501 – 509
CHAPTER 18
1801 – 1810
CHAPTER 19
1901 – 1915
APPENDIX J
J101 – J111
IPC
CHAPTER 1
101 – 110
CHAPTER 2
201 – 202
CHAPTER 3
301 – 314
CHAPTER 5
504
CHAPTER 6
601 – 613
CHAPTER 7
701 – 715
IFGC
CHAPTER 1
101 -110
CHAPTER 2
201 – 202
CHAPTER 3
301 – 310
CHAPTER 4
401 -416
NEC 2008
ARTICLES
90, 100, 110,
200, 215, 230,
240, 250, 310,
312, 314, 344-
352, 356, 368,
545, 550,
NOTE: THESE ARE THE MOST COMMON LOCATIONS FOR
INFORMATION ON MANUFACTURED HOME INSTALLATION. THERE
ARE OTHER LOCATIONS YOU WILL WANT TO LOOK AT THAT ARE NOT
LISTED HERE INCLUDING BUT NOT LIMITED TO HUD 3285 AND
ARIZONA STATUTES CHAPTER 37, ARTICLE 3, 4, 5, AND RULES R4-34-
101 – R4-34-1001.
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NEW QUALIFYING PARTY INSTRUCTIONS AND REQUIREMENTS Each business (Arizona)

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