
LI-214/244 Rev 4/2012
DISCIPLINARY ACTIONS DISCLOSURE (LI-214/244)
ARS §§ 32-2123 and 32-2130 & AAC R4-28-301 and AAC R4-28-303
The Disciplinary Actions Disclosure is required by ADRE to determine qualifications and suitability of the licensee to hold an Arizona Real Estate
License, Employing Broker License, Entity License, Cemetery License or a Membership Camping License, Educational School License, Educational
Instructor License or Public Report License. Check one:
Original Application. Disciplinary Actions Disclosure for Misdemeanors (immediate past 10 years); Felony-indefinitely
Renewal Application. Disciplinary Actions Disclosure for immediate past renewal period.
Failure to answer these questions truthfully may result in disciplinary actions including, but not limited to, suspension, revocation and/ or civil penalties
.
ARS §§ 32-2153(B) and 32-2160.01
Has the Applicant / I s the Applicant:
1
Had a professional or occupational license or registration of ANY kind denied, suspended, restricted, or revoked? (Drivers
License/ CDL not included)
YES
NO
2
Had an administrative order and/ or ANY other disciplinary action taken against ANY license issued to them by any local,
state, or federal regulatory agency?
YES
NO
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
proceeding?
YES
NO
5
Entered into ANY consent decree, and/
or had an injunction (either temporary or permanent), a suspension, an order
and/ or a judgment issued which prohibited or restricted them from engaging in ANY profession or occupation?
YES
NO
6
Had any judgment and/ or order against them by ANY
court involving fraud, dishonesty, misrepresentation, unfair trade
practice, or moral turpitude?
YES
NO
7
Had any judgment and/ or order entered against them by ANY court arising out of the conduct of any business in real
estate, cemetery property, timeshare intervals, or membership campgrounds?
YES
NO
8
Had ANY SUBDIVI SION PUBLIC REPORT or REGI STRATION TO SELL real estate, timeshares, cemetery lots, or
campground memberships denied and/ or suspended?
YES
NO
9
Had ANY payment made from the real estate recovery fund and/or ANY similar fund that was charged against them
and/ or against a business for which they were the qualifying party?
YES
NO
10
Currently involved in ANY pending disciplinary hearings and/or other administrative actions, against ANY professional
and/ or occupational licenses held in Arizona and/ or in any other state?
YES
NO
11
Held, and/ or currently holds ownership and/ or controlling
interest of 10% or more in any business, corporation,
partnership, or limited liability company that would cause them to answer “yes” to any of the above questions.
YES
NO
12
Been convicted and/ or entered into a plea agreement and/ or a plea of NOLO CONTENDERE (no contest) to ANY felony in
Arizona and/
or any other state, whether or not the plea or verdict was set aside, judgment or sentencing was deferred,
conviction was dismissed or expunged, or has been pardoned?
YES
NO
13
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
conviction was dismissed or expunged, or has been pardoned?
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.
YES
NO
14
CURRENTLY in a deferred period of judgment or sentencing, in a diversion program, and/or convicted of a Class 6
Undesignated Offense, which has not yet been designated as a felony or misdemeanor as of the date of this application?
YES
NO
15 CURRENTLY incarcerated, paroled, and/ or on probation because of ANY conviction?
YES
NO
I f the applicant answered YES to any questions 1 t hrough 14, applicant must also answer t he following:
1
Has the applicant previously disclosed the incident to ADRE in writing?
YES
NO
2
Approximate date of disclosure
If the incident and/ or action has not previously been disclosed to the ADRE in writing, refer to the DISCLOSURE DOCUMENT CHECKLI ST FORM
(LI -400) for a list of additional required documentation that must be submitted to ADRE before a renewal application is submitted for processing.
A fingerprint clearance card is required if there are any “YES” answers, other than a “YES” on question number 3.
ATTESTATI ON
I attest, under penalty of perjury, under the laws of the State of Arizona, that the foregoing answers and statements given in this application are
true and correct. I certify that at the time of ADRE license issuance, I will be 18 years of age or older. I certify that while licensed, I will not violate
any provisions of Real Estate Laws nor abuse the privileges of ADRE issued licenses.
Print Name Signature of Applicant Date
ADRE License# Email Address
Arizona Department of Real Estate (ADRE)
Licensing Division
www.azre.gov
2910 N. 44
th
STREET ● SUITE 100 ● PHOENIX, AZ ● 85018
JANI CE K. BREWER
GOVERNOR
JUDY LOWE
COMMI SSI ONER