Arizona Form Li 214 244 – Fill Out and Use This PDF

Arizona Department of Real Estate ( ADRE)

JANI CE K. BREWER

Licensing Division

GOVERNOR

w w w .azre.gov

JUDY LOWE

COMMI SSI ONER

2910 N. 44th STREET ● SUITE 100 ● PHOENIX, AZ ● 85018

1

Had a professional or occupational license or registration of ANY kind denied, suspended, restricted, or revoked? (Drivers

 YES

 NO

License/ CDL not included)

2

Had an administrative order and/ or ANY other disciplinary action taken against ANY license issued to them by any local,

 YES

 NO

state, or federal regulatory agency?

3

Had an action issued by the ADRE which resulted in an Accelerated Settlement Agreement (ASA)?

 YES

 NO

4

Voluntarily surrendered ANY professional or occupational license during the course of an investigation or disciplinary

 YES

 NO

proceeding?

5

Entered into ANY consent decree, and/ or had an injunction (either temporary or permanent), a suspension, an order

 YES

 NO

and/ or a judgment issued which prohibited or restricted them from engaging in ANY profession or occupation?

6

Had any judgment and/ or order against them by ANY court involving fraud, dishonesty, misrepresentation, unfair trade

 YES

 NO

practice, or moral turpitude?

7

Had any judgment and/ or order entered against them by ANY court arising out of the conduct of any business in real

 YES

 NO

estate, cemetery property, timeshare intervals, or membership campgrounds?

8

Had ANY SUBDI VI SI ON PUBLI C REPORT or REGI STRATI ON TO SELL real estate, timeshares, cemetery lots, or

 YES

 NO

campground memberships denied and/ or suspended?

9

Had ANY payment made from the real estate recovery fund and/ or ANY similar fund that was charged against them

 YES

 NO

and/ or against a business for which they were the qualifying party?

10

Currently involved in ANY pending disciplinary hearings and/ or other

administrative actions, against ANY professional

 YES

 NO

and/ or occupational licenses held in Arizona and/ or in any other state?

11

Held, and/ or currently holds

ownership and/ or controlling interest

of 10% or more in any business, corporation,

 YES

 NO

partnership, or limited liability company that would cause them to answer “yes” to any of the above questions.

Been convicted and/ or entered into a plea agreement and/ or a plea of NOLO CONTENDERE (no contest) to ANY felony in

12

Arizona and/ or any other state, whether or not the plea or verdict was set aside, judgment or sentencing was deferred,

 YES

 NO

conviction was dismissed or expunged, or has been pardoned?

Been convicted or entered into a plea agreement or a plea of NOLO CONTENDERE (no contest) to ANY misdemeanor in

Arizona or any other state, whether or not the plea or verdict was set aside, judgment or sentencing was deferred, the

13

conviction was dismissed or expunged, or has been pardoned?

 YES

 NO

CONVI CTI ONS – DUI AND/ OR RECKLESS DRI VI NG, EI THER MI SDEMEANOR OR FELONY, MUST BE DI SCLOSED

Minor traffic citations do not constitute a misdemeanor or felony offense.

14

CURRENTLY in a deferred period of judgment or sentencing, in a diversion program, and/ or convicted of a Class 6

 YES

 NO

Undesignated Offense, which has not yet been designated as a felony or misdemeanor as of the date of this application?

15

CURRENTLY incarcerated, paroled, and/ or on probation because of ANY conviction?

 YES

 NO

I f the applicant answ ered YES to any questions 1 through 14, applicant must also answ er the follow ing:

1

Has the applicant previously disclosed the incident to ADRE in writing?

 YES

 NO

2

Approximate date of disclosure

Type of disclosure

Print Name

Signature of Applicant

Date