STATE OF ARIZONA
DEPARTMENT OF HOUSING
P.O. BOX 6280
PHOENIX, ARIZONA 85005-6280
602-771-1000 FAX: 602-771-1002
SALESPERSON LICENSE RENEWAL
FORM
NA
ME:
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. The yearly fee for your license renewal is: $103.00. This fee MUST be
paid PRIOR to your renewal date or the fee will be 125% of the regular annual fee or $128.75. No exceptions can
be allowed for a LATE RENEWAL. *License can only be late renewed up to one year from the date it is non-
renewed. **Make checks payable to Arizona Department of Housing. Mail completed form and your payment to the
P.O. Box stated above.
Your Annual Renewal Certificate EXPIRES on:
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 since the date that your license was 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
m
isrepresentation? YES NO
4. Has any governmental agency (excluding this agency) issued a disciplinary action against you or your
li
cense? YES NO
5. Are you currently employed by a dealer? YES NO
If “YES”, provide your employing dealer's name:
and dealer license number:
The LICENSED SALESPERSON must sign this document.
SIGNATURE OF LICENSEE:
DATE:
PRINTED NAME OF LICENSEE:
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
