Fillable PETITION FOR DETERMINATI ON (Arizona)

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PETITION FOR DETERMINATI ON (Arizona)

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100 North 15 Avenue, Suite 261 | Phoenix, Arizona 85007-2630
Page 1 of 2
FORM L-PFD 20220601
FORM L-PFD
PETITION FOR DETERMINATI ON
INSURANCE LICENSING
602-364-4457
insurancelicensing@difi.az.gov
FINANCIAL ENTERPRISES/APPRAISERS
602-771-
2800
felicensing@difi.az.gov
• If you have a criminal record, Arizona Revised Statutes (“A.R.S.”) § 41-1093.04 allows you to petition the
department in advance of your fulfilling license application requirements in order to determine whether your
criminal record disqualifies you from becoming licensed.
• IMPORTANT: A
PETITION APPLIES ONLY TO CRIMINAL HISTORY. A license may be denied, suspended, revoked or
refused based on factors
OTHER THAN criminal history.
• Y
OUR PETITION MUST BE COMPLETE OR IT WILL BE REJECTED and not processed. Upon receiving a complete petition,
we may take up to 90 days to determine whether you are disqualified from becoming licensed.
1) APPLICANT INFORMATION. Enter your full name, mailing and email address:
FIRST NAME
MIDDLE NAME
CITY
STATE
ZIP CODE
2) LICENSE TYPE. Check a box to indicate the type of license for which you are applying:
Adjuster
Loan Originator
Appraiser
Navigator
Bail Bond Agent
Producer
Certified Application Counselor
Property Tax Agent
3) CRIMINAL HISTORY. Your entire criminal history record (per ARS § 41-1093.04(B)(1))
a) LIST ALL CRIMINAL CONVICTIONS AND JUDGMENTS, including those that were dismissed, expunged, pardoned,
appealed, set aside, vacated or reversed, regardless of whether you had civil rights restored, had a plea
withdrawn, or were given probation, a suspended sentence, a fine or successfully completed a diversion program.
For more than five convictions, attach an additional sheet to provide information about the other cases.
CASE NUMBER
CLASSIFICATION
CRIME/VIOLATION
DISPOSITION
1
2
3
4
5
b) FOR EACH CONVICTION/JUDGMENT, YOU MUST SUBMIT WITH THIS FORM copies of (1) the complaint issued against you,
(2) the indictment, (3) the conviction or judgment or plea agreement, and (4) all documents you have that show
you fulfilled all court-ordered incarceration, probation, rehabilitation, penalty-payment requirements and
restitution-payment requirements.
APPLICANT NAME
Page 2 of 2 FORM L-PFD 20220601
4) RESTITUTION. You must include all of the following additional information about your current circumstances (per
ARS § 41-1093.04(B)(2)). Include all payment receipts and other court documents that show the payments for
restitution made by you.
Payment of court-ordered restitution:
AMOUNT ORDERED
$
AMOUNT PAID
$
5) EMPLOYMENT HISTORY. Your employment history from and after the date of your earliest conviction (Attach an
additional sheet if necessary):
NAME OF EMPLOYER
POSITION HELD
FROM
(mm/yy)
TO
(mm/yy)
1
2
3
4
5
6
a) Your employment aspirations: Describe the jobs/positions that you want to have in the short- and long-term.
b) Evidence of rehabilitation and testimonials: You MUST attach documents that show that you have been
rehabilitated and not likely to reoffend. Include at least one testimonial from another person that contains:
• their name, phone number and email address;
• their description about how they know you;
• their opinion about your rehabilitation, character, and the likelihood that you will reoffend.
6) SIGNATURE.
I certify, under any penalty that may apply, that the answers, statements, and information furnished in connection with this request for pre-
determination are true, correct, and complete to the best of my knowledge and belief and that all criminal convictions are being disclosed on this
request.
APPLICANT’S SIGNATURE DATE
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PETITION FOR DETERMINATI ON (Arizona)

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Completed 1 July 2022

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