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SECTION 1: INCOMING DESIGNATED BROKER (DB) INFORMATION an (Arizona Department of Real Estate)

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ENTITY / EMPLOYING BROKER LICENSE APPLICATION (LI-212)
ARS §32-2125 & R4-28-302
SECTION 1: INCOMING DESIGNATED BROKER (DB) INFORMATION – an answer must be provided to a
ll questions
Incoming DB Name (First MI Last):
Incoming DB License #:
Incoming DB License Expire Date:
Email
Phone:
Fax:
Questions Responses
1 How is the incoming DB currently licensed?
DB SE
(attach LI201A)
Associate Broker Salesperson
2 Is the incoming DB currently employed as “active status”?
Yes
No
Go to question 6
3 Is the current entity closing?
Yes
Go to Question 5
No
4 Is that current entity appointing a new DB?
Yes
Go to question 6
No
5 Does the current entity have “active” agents? (If yes, refer to instructions)
Yes
No
6
As the incoming Designated Broker, are continuing education (CE)
requirements current? ARS § 32-2130
Yes
No – STOP
Re-apply when current
7
As the incoming Designated Broker, has the Broker Management Clinic been
completed within 24 months prior to this application? ARS § 32-2136(C)
Yes
Date:_______________
No – STOP
Re-apply when current
8
Is there a joint PC or PLLC with the ADRE for this DB’s name? ARS §32-2125(B)
YES
– STOP
Amend to single PC or PLLC
with the ACC and re-apply
No
9 Does DB have a PC or PLLC in good standing with the ACC?
Yes
No - STOP
Re-apply
10 Will this DB reside outside the State of Arizona?
Yes
Complete Section 5
No
Check if Non-resident Broker – complete Section 5 of this application
SECTION 2: ENTITY/EMPLOYING BROKER INFORMATION – attach ADRE “Entity/Employing Broker Name Reservation Approval
Notification”
Legal Name (as approved by ADRE) EIN (Employer Identification
Number)
or Tax ID# (Required)
Doing Business As (DBA) – if any (as approved by ADRE)
Physical Address of Entity: Suite City State Zip
Mailing Address: Same as above
Suite
City
Zip
Email: Phone: Fax:
ADRE USE ONLY
License Number: Expiration Date (Aligned)
LI-212 Rev 8/2019
Page 1 of 4
Arizona Department of Real Estate (ADRE)
Licensing Division
www.azre.gov
DOUGLAS A. DUCEY
GOVERNOR
JUDY
LOWE
COMMISSIONER
100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007
SECTION 3: BROKERAGE TYPE – R4-28-302
• Each member, manager or person controlling or holding 10% or more interest in the CO, LLC or PA must complete the Disciplinary
Actions Disclosure (Form LI-214/244)
• Any “Yes” responses will require the completion and submission of all documents pursuant to the Disciplinary Actions Disclosure
(Form LI-400) and a Fingerprint Clearance Card issued by the Arizona Department of Public Safety (DPS)
The following documents are required to be attached with the application for EACH Brokerage type:
Limited Liability Company(LLC)
Member Controlled
Manager Controlled
R4-28-302(D)
A copy of the Original Articles of Organization and any amended articles stamped “FILED”
by the Arizona Corporation Commission (ACC).
A copy of the resolution signed by members stating:
Whether management of LLC is established as manager / member controlled;
The name of the member / manager to act as the DB.
A list of the names and addresses of all members and managers, and any person
controlling or holding interest of 10% or more interest in the Limited Liability Company.
Corporation (CO)
R4-28-302(C)
A copy of the Articles of Incorporation and any amended articles stamped “FILED” by the
Arizona Corporation Commission (ACC).
A copy of the resolution signed by all officers and directors electing/appointing a DB as a
corporate officer, naming the office held, and stating that the individual was appointed
to act as the DB for the Corporation.
A list of the names and addresses of: all officers and directors; and each
shareholder/entity controlling or holding 10% or more interest in the Corporation.
General Partnership (PA)
R4-28-302(B)
A copy of the Partnership Agreement and any amendments from the county in which it is
registered.
A partnership agreement signed by all partners, appointing a partner to act as DB.
The names and addresses of: all partners, and any other person with a beneficial or
membership interest in the partnership.
Limited Partnership (LP)
R4-28-302(B)
A copy of the Application of Registration and any amendments stamped “FILED” by the
Secretary of State.
A partnership agreement signed by all partners, appointing a partner to act as DB
The Designated Broker(DB) shall be:
A partner of the general partner if the general partner is a partnership;
A member of the member-managed limited liability company or manager of the
manager-managed limited liability company if the general partner is a limited
liability company;
A corporate officer of the corporate partner if the general partner is a corporation;
A limited partner of a partnership shall not be DB for the partnership.
Limited Liability Partnership
(LLP)
R4-28-302(B)
A copy of the Original Articles of Organization and any amended articles stamped “FILED”
by the Arizona Corporation Commission (ACC).
A partnership agreement signed by all partners, appointing a partner to act as DB
The Designated Broker(DB) shall be:
A partner of the general partner if the general partner is a partnership;
A member of the member-managed limited liability company or manager of the
manager-managed limited liability company if the general partner is a limited
liability company;
A corporate officer of the corporate partner if the general partner is a corporation;
A limited partner of a partnership shall not be DB for the partnership.
Foreign Entity
LLC
CO
PA
R4-28-302(E)
A copy of the Original Articles and any amendments stamped “FILED” from the State of
origin.
A certificate of good standing from the state from the State of origin.
A copy of the Application of Authority to conduct business as a foreign entity in Arizona
stamped “FILED” from the Arizona Corporation Commission.
A list of the names and addresses of all members/managers, and any person/entity that
have controlling interest of 10% or more in the limited liability company.
Additional documents as required above in the LLC, CO or PA sections.
LI-212 Rev 8/2019
Page 2 of 4
SECTION 4: TRUST ACCOUNT INFORMATION – established with a Financial Institution located in Arizona, if the broker is holding client funds.
ARS § 32-28-302(A)
Check if using Arizona Based Title Company only – skip to Section 4
Trust Account Name Trust Account Number
Financial Institution Name Phone: Fax:
Branch Address:
Street # Street Name Suite City State
Zip
Trust Account Name Trust Account Number
Financial Institution Name Phone: Fax:
Branch Address:
Street # Street Name Suite City State Zip
Tr
ust Account Name Trust Account Number
Financial Institution Name Phone: Fax:
Branch Address:
Street # Street Name Suite City State Zip
Additional account information attached.
SECTION 5: NON-RESIDENT EMPLOYING BROKER INFORMATION – ARS §§32-2151.01(A); 32-2163 and R4-28-302(L)
A non-resident broker who maintains a principal office outside of Arizona shall:
Establish a trust account in Arizona – enter information in Section 4
Maintain all records of transaction(s) in Arizona –
Appoint a Custodian of Records
Custodian Name:
Address:
Email: Phone: Fax:
A non-resident Employing Broker who employs any licensee(s) in the State of Arizona shall complete
below:
Establish a branch office and appoint an Arizona licensed Branch Manager other than self.
Branch Office Information (of non-resident Employing Broker)
Legal Name
Phone:
Doing Business As (DBA) – if any Fax:
Business Address: Suite City State Zip
Mailing Address: Same as above
Su
ite
Ci
ty
Sta
te
Zi
p
Branch Manager (of non-resident Employing Broker)
Name (First MI Last): License #: License Expiration Date:
Email: Phone: Fax:
LI-212 Rev 8/2019
Page 3 of 4
Des
cribe the authority vested in the branch manager
– ARS §32-2127 and R4-28-304
Describe how the licensed employee(s) will be supervised – R4-28-203(L) & R4-28-1103
I, acknowledge that I have read and understand the responsibilities set forth above.
Branch Manager Name
Branch Manager Signature Date
SECTION 6: FINAL CHECKLIST: All documents must be submitted in order as listed below.
INCOMPLETE APPLICATIONS WILL BE RETURNED UNPROCESSED
A NEW COMPLETED APPLICATION MUST THEN BE RE-SUBMITTED AND WILL BE PROCESSED IN THE ORDER RECEIVED
Entity/Employing Broker License Application (LI-212) - completed
ADRE Entity/Employing Broker Name Reservation Notice (ADRE Approval)
Disciplinary Actions Disclosure Form (LI 214/244) completed by the Designated Broker (DB) and each member, manager or person
controlling or holding 10% or more interest in the CO, LLC or PA
Any “Yes” responses will require the completion and submission of all documents pursuant to the
Disciplinary Actions Disclosure (Form LI-400) and a Fingerprint Clearance Card issued by the
Arizona Department of Public Safety (DPS)
All documents as required in Section 3 for the Entity type selected
Additional Trust Account Information – if applicable
DB/SE Letter of Resignation from current employment, if currently in an active status.
Certificate of Broker Management Clinic (Completion date not to exceed 24 months prior to application)
Entity Broker Status Change (Form LI-216)) – When DB changes from one entity to another.
SECTION 7: DESIGNATED BROKER STATEMENT OF ATTESTATION – required of all entity types-ACC R4-28-302
As the Designated broker for , I attest that:
A. The above named Entity / Employing Broker has applied for a broker’s license in Arizona;
B. That each: officer/director member/manager partner,
has read the completed application on the above named entity as submitted to the Department;
C. All the information contained in this application is true;
D. That each: officer/director member/manager partner,
Is qualified to do business in Arizona.
E. That the entity is in good standing with the Az. Corporation Commission (ACC) or Secretary of State (SOS).
Designated Broker Signature Date Designated Broker Name
LI-212 Rev 8/2019
Page 4 of 4
click to sign
signature
click to edit
Notice to Applicant Pursuant to A.R.S. § 41-1030
An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically
authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for
imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically
authorizes the requirement or condition.
This section may be enforced in a private civil action and relief may be awarded against the State. The court may award
reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action
against the state for a violation of this section.
A State employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action
or dismissal pursuant to the Agency's adopted personnel policy.
This section does not abrogate the immunity provided by section 12-820.01 or 12-
820.02
Notice to Applicant Pursuant to A.R.S. § 41-1093.01
A
n agency shall limit all occupational regulations to regulations that are demonstrated to be necessary to specifically fulfill a
public health, safety or welfare concern. Pursuant to sections 41-1093.02 and 41-1093.03, Arizona Revised statutes, you have
the right to petition this agency to repeal or modify the occupational regulation or bring an action in a court of general jurisdiction
to challenge the occupational regulation and to ensure compliance with section 41-1093.01, Arizona Revised Statutes.
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SECTION 1: INCOMING DESIGNATED BROKER (DB) INFORMATION an (Arizona Department of Real Estate)

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Completed 20 July 2020

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