ADRE Lic Form LI-202 Salesperson-Broker Change rev 08 22 2013

ARIZONA DEPARTMENT OF REAL ESTATE (ADRE) Licensing Division

www.azre.gov 100 North 15th Avenue, Suite 201, Phoenix, Arizona 85007

DOUGLAS A. DUCEYGOVERNOR

JUDY LOWE

COMMISSIONER

SALESPERSON / ASSOCIATE BROKER CHANGE (FORM LI-202) To be used only by Licensees with ADRE Departmental Matters

Salesperson or Associate Broker Information Licensee Name (Print): License Number: Expiration Date: Email Address:

Licensee Signature

X Date

Provisional License or Departmental Matter? Yes No

Provisional License Other Departmental Matter

Type of Change Being Made HIRE

TRANSFER

SEVER

Licensee HIRE/TRANSFER Agent To Hiring Entity Legal Name: Hiring Entity License Number:

Hiring Entity DBA Name:

Physical Address (Branch): Suite: City: State: Zip Code: County:

Phone: Fax:

Hiring Designated Broker Name (Print): Hiring DB License Number:

Hiring Designated Broker Signature

X

Date:

SEVER Agent From Severing Entity Legal Name: Severing Entity License Number:

Severing Designated Broker Name (Print): Severing DB License Number:

Severing Designated Broker Signature

X Date:

ADRE LICENSING USE ONLY

Effective Date Date Stamp Receipt

Input Date

Time Frame TF-1 TF-2

Processed By

ADRE E&C USE ONLY

E&C SIGNATURE DATE ORDER