salesperson / associate broker change (form li-202) to be used
Post on 04-Feb-2022
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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
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