STATE OF ARIZONA
DEPARTMENT OF HOUSING
P.O. BOX 6280
PHOENIX, ARIZONA 85005-6280
(602) 771-1000 FAX: (602) 771-1002
BUSINESS LICENSE RENEWAL FORM
NAME:
ADDRESS:
CITY: STATE: ZIP:
LICENSE NUMBER:
DO NOT DESTROY THIS DOCUMENT -- THIS IS YOUR LICENSE RENEWAL FORM. YOUR LICENSE WILL BE
RENEWED ONLY WHEN THIS FORM IS FULLY COMPLETED AND RETURNED TO THIS DEPARTMENT WITH
THE REQUIRED NONREFUNDABLE FEE. MAKE CHECK PAYABLE TO THE ARIZONA DEPARTMENT OF
HOUSING. MAIL THE COMPLETED RENEWAL AND YOUR PAYMENT TO THE P.O. BOX STATED ABOVE.
Your Annual Renewal Certificate EXPIRES on:
The yearly renewal fee for your license is:
This fee MUST be paid PRIOR to your renewal date or the fee will be 125% of the regular annual fee. No
exceptions can be allowed for a LATE RENEWAL
LATE RENEWAL FEE for your license is:
All questions listed below MUST be answered either (YES) or (NO). A (YES) answer to any question
requires an attached statement giving complete details.
SINCE YOUR LAST RENEWAL OR DATE LICENSE FIRST ISSUED IF THIS IS YOUR FIRST RENEWAL:
1. Have you been detained, cited, arrested, indicted or summoned into court for a felony?
YES NO
2. Have you been convicted of a felony which remains a part of your record or, have you been
pardoned or had your criminal record expunged? YES NO
3. Has anyone obtained a judgment against you in any civil action, the subject of which involved fraud
or misrepresentation? YES NO
4. Has any governmental agency (including this agency) issued a disciplinary action against you or
your license? YES NO
The QUALIFYING PARTY MUST sign this document:
SIGNATURE OF QUALIFYING PARTY:
PRINTED NAME OF QUALIFYING PARTY:
DATE:
NOTE: RENEWAL IS YOUR RESPONSIBILITY! IF YOU HAVE HAD A
CHANGE OF CITIZENSHIP SINCE YOUR LAST RENEWAL, YOU
MUST PROVIDE US WITH PROOF YOU HAVE THE RIGHT TO LIVE
AND WORK IN THE UNITED STATES.
For Office Use Only
Receipt #
Amount:
Check #
Received:
