1110 WEST WASHINGTON, SUITE 280
PHOENIX, ARIZONA 85007
PHONE: 602-771-1000 | FAX: 602-771-1002
WWW.AZHOUSING.GOV
Company Name and Mailing Address of Licensee:
_______________________________________________________
_______________________________________________________
_______________________________________________________
License Number: ___________________ Classification: ___________________ Telephone: _________________________
Email: ________________________________________________________________________________________________
Qualifying Party Name: _________________________________________________________________________________
Mailing Preference:
Mail Pickup FedEx UPS
FedEx or UPS Account Number: _______________________________
A Certificate Report is required to be submitted to the Department by:
Installer 15
th
of each month
Manufacturer 5
th
of each month
Visit our website to acquire Certificate Report form: www.azhousing.gov
CERTIFICATE SERIAL NUMBER(S) ASSIGNED:
(Section below is for office use only, please leave blank)
TYPE OF CERTIFICATE ORDERED
DESCRIPTION FEE QTY
Installation Certificate
Residential Use
FBB Commercial Use
$10.00 each
Modular Manufacturer
Certificate
$51.00 each
Reconstruction
Certificate
$51.00 each
Receipt No:
Check No:
Amount:
Date Issued:
Order filled by:
CERTIFICATE ORDER APPLICATION
(Certificates can ONLY be issued to the Qualifying Party or Corporate Officer of the license)
