Douglas A. Ducey, Governor Jeff Fleetham, Director L A ......Douglas A. Ducey, Governor Jeff Fleetham, Director 1700 W. Washington Street, Suite 105 Phoenix AZ 85007-2812 602.542.1525

ARIZONA REGISTRAR OF CONTRACTORS

Douglas A. Ducey, Governor Jeff Fleetham, Director

1700 W. Washington Street, Suite 105 ● Phoenix AZ 85007-2812 602.542.1525 ● Within AZ 877.692.9762 ● Fax 602.542.1599 ● www.roc.az.gov

License Application (LLC) Form RC-L-200B Rev. December 23, 2020 Instructions

LICENSE APPLICATION (LIMITED LIABILITY COMPANY)

THIS APPLICATION IS FOR LLCS ONLY This License Application is for an LLC seeking to obtain an Arizona Contractor’s License.

If the Applicant is a sole-proprietorship, use the Sole-Proprietorship License Application Form. A sole proprietorship is a business owned and controlled by one person.

If the Applicant is a corporation, use the Corporation License Application Form.

If the Applicant is a partnership, use the Partnership License Application Form.

If the Applicant is a tiered entity, please contact the Registrar’s Licensing Department at (602) 542-1525 for assistance. A Tiered Entity is an entity that is owned or operated by another entity.

• For example, if “Red Corporation” is owned or operated by “Blue, LLC,” “Red Corporation” wouldbe considered a Tiered Entity for the purposes of obtaining a contractor’s license.

STEPS TO OBTAIN A CONTRACTOR’S LICENSE To obtain an Arizona Contractor’s License, complete the following:

1) Identify a Qualifying Party: The Applicant must identify a Qualifying Party for the license. AQualifying Party is a regularly employed person with the necessary experience, knowledge andskills as defined under A.R.S. § 32-1122(E).

2) Pass Examination(s). The Qualifying Party must pass the required exams by at least 70% andsubmit exam results. The Qualifying Party must complete a statutes and rules exam (SRE) and aspecific trade exam, unless eligible for a waiver.

• To determine which exams are required for a specific license classification, refer to theRegistrar’s License Classification Requirements.

• The Qualifying Party can register to take an exam through PSI Exams Online.• For information about PSI’s testing procedures, refer to PSI's Candidate Information

Bulletin.3) Submit to Background Checks. The Qualifying Party listed in Part 2, and each individual listed in

Part 3: Persons in this License Application must submit copies of the payment transactionreceipt from their background checks.

4) Form a Legal Entity. Form or register an LLC with the Arizona Corporation Commission.5) Bond. The Applicant must obtain and submit proof of a license Bond.6) Pay the Fees. Include the required fees and assessments with your License Application form.

(continued on next page)

http://www.roc.az.gov/https://roc.az.gov/sites/default/files/forms/RC-L-200A-License%20Application-Sole%20Prop.pdfhttps://roc.az.gov/sites/default/files/forms/RC-L-200C%20-License-Application-Corporation.pdfhttps://roc.az.gov/sites/default/files/forms/RC-L-200D-License-Application-Partnerships_0.pdfhttps://roc.az.gov/sites/default/files/files/2017_License_Classification_Requirements.pdfhttps://candidate.psiexams.com/catalog/displayagencylicenses.jsp?catalogID=337https://candidate.psiexams.com/bulletin/display_bulletin.jsp?ro=yes&actionname=83&bulletinid=503&bulletinurl=.pdfhttps://candidate.psiexams.com/bulletin/display_bulletin.jsp?ro=yes&actionname=83&bulletinid=503&bulletinurl=.pdfhttps://roc.az.gov/background-checkshttp://www.azcc.gov/https://roc.az.gov/bond-informationhttps://roc.az.gov/license-fees

ARIZONA REGISTRAR OF CONTRACTORS

Douglas A. Ducey, Governor Jeff Fleetham, Director


License Application (LLC) Form RC-L-200B Rev. December 23, 2020 Instructions

7) Government-Issued Identification. The Qualifying Party listed in Part 2, and each individuallisted in Part 3: Persons in this License Application must submit a copy of their governmentissued identification with the application.

8) Complete and Submit This Application. Complete and submit this License Application Form tothe Registrar using one of the following methods:

Mail to: Registrar of Contractors P.O. Box 6748 Phoenix, AZ 85005-6748

Hand-deliver to: Registrar of Contractors 1700 W. Washington Street, Suite 105 Phoenix, AZ 85007-2812

Apply Online at: https://roc.az.gov/online-services

WAIVERS Some of the requirements listed above may be waived depending on an Applicant’s past experience in the contracting field. To determine if a waiver applies to your application, refer to the Registrar’s online Waiver Eligibility page.

AGENCY DISCLOSURE Pursuant to A.R.S. § 41-1030(G), the Registrar provides the following disclosures:

• A.R.S. § 41-1030(B): An agency shall not base a licensing decision in whole or in part on alicensing requirement or condition that is not specifically authorized by statute, rule or statetribal gaming compact. A general grant of authority in statute does not constitute a basis forimposing a licensing requirement or condition unless a rule is made pursuant to that generalgrant of authority that specifically authorizes the requirement or condition.

• A.R.S. § 41-1030(D): This section may be enforced in a private civil action and relief may beawarded against the state. The court may award reasonable attorney fees, damages and all feesassociated with the license application to a party that prevails in an action against the state for aviolation of this section.

• A.R.S. § 41-1030(E): A state employee may not intentionally or knowingly violate this section. Aviolation of this section is cause for disciplinary action or dismissal pursuant to the agency'sadopted personnel policy.

• A.R.S. § 41-1030(F): This section does not abrogate the immunity provided by § 12-820.01 or 12-820.02.

***DO NOT SUBMIT THESE INSTRUCTIONS WITH YOUR APPLICATION***

http://www.roc.az.gov/https://roc.az.gov/online-serviceshttps://roc.az.gov/applying-license#waiver


License Application (LLC) Form RC-L-200B Rev. December 23, 2020 Page 1 of 11

Form RC-L-200B

LICENSE APPLICATION (LLC)

For Internal Use Only

Pending #______________

PART 1: APPLICANT INFORMATION To avoid delay or denial, the Applicant must completely and accurately fill out the following information.

• An Authorized Representative is a person with the authority to sign on behalf of the LLC. • The business address you provide will be publicly available on the Registrar’s website.

o An applicant must provide an address or location of the applicant’s place of business, and a mailing address if it is different from the applicant’s place of business. A.R.S. § 32-1122(B)(1)(h).

• To determine the appropriate License Classification Description in box 5, refer to the Registrar’s License Classifications located at https://roc.az.gov/license-classifications.

1. Limited Liability Company Name 2. Fictitious Trade Name (i.e. DBA), if applicable.

3. Authorized Representative’s Name 4. Arizona Corporation Commission File Number

5. Requested License Classification Description

6. Business Address (No PO Boxes or Private Mail Boxes) City State Zip Code

7. Mailing Address (If different than business address) City State Zip Code

8. Phone Number 9. Email Address

10. Prior to completing this application, did you or any other member of your organization participate in or watch a video of the Registrar’s ‘Applicant Education Seminar’?

(Yes) (No)CONSENT Enter [Email / Telephone]

10. I consent to receive notifications from the Registrar byemail at the following email address ..........................................................

11. I consent to receive notifications from the Registrar bytext messaging at the following telephone number ....................

Workers’ Compensation Coverage Applicants are required to be in compliance with the statutes and rules governing Workers’ Compensation coverage. See A.R.S. § 32-1122(B)(1)(i). In general, if you have any employees, you must have Workers' Compensation insurance. Please choose your Workers’ Compensation Coverage type from the list below: 1. Workers’ CompensationInsurance:

Policy Number Company Issuing Policy

2. Self-Insured Employer (You Must Submit Documentation Showing Proof of Coverage with this Application)

3. Exemption: Single-Member LLC without any employees, or 50/50 Two-Member LLC without any employees. (YES) (NO)

http://www.roc.az.gov/https://roc.az.gov/license-classifications



PART 2: QUALIFYING PARTY QUALIFYING PARTY

The "Qualifying Party" is a person who is regularly employed by the Applicant and is actively engaged in the classification of work for which the person qualifies on behalf of the Applicant. The Qualifying Party must have the necessary experience, knowledge and skills to supervise or perform the contracting work.

A.R.S. § 32-1127 The Qualifying Party listed below may be listed as the qualifying party for up to two licensees, but only when:

1. There is a common ownership of at least twenty-five per cent of each licensed entity for which the person acts in a qualifying capacity; or

2. One licensee is a subsidiary of another licensee for which the same person acts in a qualifying capacity. "Subsidiary" as used in this section means a corporation of which at least twenty-five per cent is owned by the other licensee.

1. Name as it appears on your government issued ID 2. Title/Position 3. Ownership %

4. Date of Birth (MM/DD/YYYY) 5. Driver’s License or Government ID No. 6. Social Security Number 7. Are you a U.S.

Citizen?

8. Residential Address City State Zip Code

9. Mailing Address (If different than residential address) City State Zip Code


CONSENT Enter [Email / Telephone]

12. I consent to receive notifications from the Registrarby email at the following email address .............................................

13. I consent to receive notifications from the Registrarby text messaging at the following telephone number ....... “Notifications” include renewal notices and monthly newsletters. By consenting to receive notifications via text or email, you will not be excluded from receiving notifications by regular mail. You consent by entering the information above.

RELEVANT EXPERIENCE The Qualifying Party must demonstrate sufficient experience as required by the desired license classification. The required amount of experience can be determined by referring to the License Classification Requirements table. Technical training, military service, diplomas, or certifications may be submitted to substantiate experience, or a portion of experience.

• Under A.R.S. § 32-1122(E)(1), at least two years of experience must be earned within the last ten years. • If additional space is needed, complete and attach as many “Additional Relevant Experience” pages as necessary.

1. Business Name of Employer or “Self-Employed”

2. Duration of Experience (e.g. “1/1/2007 through 1/1/2017”) 3. Average Hours Worked Per Week

4. Position(s) 5. Size of Projects Qualifying Party Worked On (Square Foot and/or Dollar Amount)

http://www.roc.az.gov/https://www.azleg.gov/ars/32/01127.htmhttps://roc.az.gov/sites/default/files/files/2017_License_Classification_Requirements.pdf



6. Description of Qualifying Party’s Main Duties

EXPERIENCE REFERENCE Include the name and contact information for a reference who can verify the Qualifying Party’s experience. The reference must have direct, first-hand knowledge of the Qualifying Party’s experience. The reference cannot be a person named on the license application. 7 Reference’s Name 8. Reference’s Relationship to Qualifying Party (e.g. “Co-worker”; “Employer”; “Supervisor”)

9. References Mailing Address City State Zip Code

10. Reference’s Phone Number 11. Reference’s E-mail

http://www.roc.az.gov/



ADDITIONAL RELEVANT EXPERIENCE (IF NECESSARY) The Qualifying Party must demonstrate sufficient experience as required by the desired license classification. The required amount of experience can be determined by referring to the License Classification Requirements table. Technical training, military service, diplomas, or certifications may be submitted to substantiate experience, or a portion of experience.

• Under A.R.S. § 32-1122(E)(1), at least two years of experience must be earned within the last ten years prior. • If additional space is needed, complete and attach as many “Additional Relevant Experience” pages as necessary.

1. Business Name of Employer or “Self-Employed”

2. Duration of Experience (e.g. “1/1/2007 through 1/1/2017”) 3. Average Hours Worked Per Week

4. Position(s) 5. Size of Projects Qualifying Party Worked On (Square Foot and/or Dollar Amount)

6. Description of Qualifying Party’s Main Duties

EXPERIENCE REFERENCE Include the name and contact information for a reference who can verify the Qualifying Party’s experience. The reference must have direct, first-hand knowledge of the Qualifying Party’s experience. The reference cannot be a person named on the license application. 7 Reference’s Name 8. Reference’s Relationship to Qualifying Party (e.g. “Co-worker”; “Employer”; “Supervisor”)

9. References Mailing Address City State Zip Code

10. Reference’s Phone Number 11. Reference’s E-mail

http://www.roc.az.gov/https://roc.az.gov/sites/default/files/files/2017_License_Classification_Requirements.pdf



PART 3: PERSONS

COMPLETE AND ATTACH ADDITIONAL PART 3S AS NECESSARY TO PROVIDE THE INFORMATION FOR ALL OF THE FOLLOWING PERSONS ON THE LICENSE.

• Owners of 25% or more of the stock or beneficial interest of the LLC. • If the Applicant is a Member-Managed LLC, then complete Part 3 for each Member. • If the Applicant is a Manager-Managed LLC, then complete Part 3 for each Manager.

This information is required under A.R.S. § 32-1122(B)(1)(d). Every person listed on this application must be 18 years of age or older and must sign this application form under Part 6: Signatures.

Arizona Corporation Commission Documents To determine which individuals are members or managers of an LLC, refer to the LLC’s entity documents. Entity documents can be located using the Corporation Commission’s search tool located at http://ecorp.azcc.gov/Search.

• If any corporation, LLC, partnership, trust, or other business organization is listed on the applying entity’s Arizona Corporation Commissiondocuments, then please contact the Registrar’s Licensing Department at (602) 542-1525 for assistance on completing the tiered entity organization chart.

This application is for a:

Member-Managed LLC Manager-Managed LLC MEMBER / MANAGER

The Registrar requires all of the information below for each member (if the applicant is a member-managed LLC) or each manager (if the applicant is a manager-managed LLC). 1. Name as it appears on your government-Issued ID

2. Title/Position (“Member” or “Manager”) 3. Ownership % 4. Date of Birth (MM/DD/YYYY)

5. Identification No. (Driver’s License or Government ID No.) 6. Social Security Number 7. Are you a U.S. Citizen?

8. Business or Residential Address City State Zip Code

9. Mailing Address (If different than business or residential

address)

City State Zip Code


CONSENT Enter [Email / Telephone] 12. I consent to receive notifications from the Registrar by email atthe following email address ......................................................................................................

13. I consent to receive notifications from the Registrar by textmessaging at the following telephone number ..................................................... “Notifications” include renewal notices and monthly newsletters. By consenting to receive notifications viatext or email, you will not be excluded from receiving notifications by regular mail. You consent by entering

http://www.roc.az.gov/http://ecorp.azcc.gov/Searchhttps://roc.az.gov/sites/default/files/forms/RC-L-%20205D%20Tiered%20Entity%20Org%20Chart%20Inst._0.pdfhttps://roc.az.gov/sites/default/files/forms/RC-L-%20205D%20Tiered%20Entity%20Org%20Chart%20Inst._0.pdf



the information above. MEMBER / MANAGER

The Registrar requires all of the information below for each member (if the applicant is a member-managed LLC) or each manager (if the applicant is a manager-managed LLC) 1. Name as it appears on your government-Issued ID





address)

City State Zip Code



12. I consent to receive notifications from the Registrar by email atthe following email address ......................................................................................................

13. I consent to receive notifications from the Registrar by textmessaging at the following telephone number ..................................................... “Notifications” include renewal notices and monthly newsletters. By consenting to receive notifications viatext or email, you will not be excluded from receiving notifications by regular mail. You consent by entering the information above.

MEMBER / MANAGER The Registrar requires all of the information below for each member (if the applicant is a member-managed LLC) or each manager (if the applicant is a manager-managed LLC). 1. Name as it appears on your government-Issued ID





address)

City State Zip Code







13. I consent to receive notifications from the Registrarby text messaging at the following telephone number ....... “Notifications” include renewal notices and monthly newsletters. By consenting to receive notifications viatext or email, you will not be excluded from receiving notifications by regular mail. You consent by entering the information above.

MEMBER / MANAGER The Registrar requires all of the information below for each member (if the applicant is a member-managed LLC) or each manager (if the applicant is a manager-managed LLC) 1. Name as it appears on your government-Issued ID





address)

City State Zip Code




13. I consent to receive notifications from the Registrarby text messaging at the following telephone number ....... “Notifications” include renewal notices and monthly newsletters. By consenting to receive notifications viatext or email, you will not be excluded from receiving notifications by regular mail. You consent by entering the information above.

MEMBER / MANAGER The Registrar requires all of the information below for each member (if the applicant is a member-managed LLC) or each manager (if the applicant is a manager-managed LLC) 1. Name as it appears on your government-Issued ID





address)

City State Zip Code






12. I consent to receive notifications from the Registrarby email at the following email address ..........................................

13. I consent to receive notifications from the Registrarby text messaging at the following telephone number .... “Notifications” include renewal notices and monthly newsletters. By consenting to receive notifications viatext or email, you will not be excluded from receiving notifications by regular mail. You consent by entering the information above.




PART 4: DISCLOSURES

• PRIOR LICENSE INFORMATION Circle One 1. Has the Qualifying Party ever been named on a license in any state that was revokedor is currently suspended? Failure to accurately answer this question may be a material misrepresentation of fact and a violation of A.R.S. § 32-1154(A)(5).

(Yes) (No)

2. Has any individual listed in Part 3: Persons of this application ever been named on alicense in any state that was revoked or is currently suspended? Failure to accurately answer this question may be a material misrepresentation of fact and a violation of A.R.S. § 32-1154(A)(5).

(Yes) (No)

FELONY CHARGES Answering ‘yes’ does not automatically disqualify the Applicant from receiving a contractor’s license. Circle One 3. Has the Qualifying Party listed in Part 2 ever been convicted of a felony? If ‘yes’ is selected, the Qualifying Party must complete and attach the Felony Disclosure Form with this application.

(Yes) (No)

4. Does the Qualifying Party listed in Part 2 have a pending felony charge that has notyet received a disposition? If ‘yes’ is selected, the Qualifying Party must complete and attach the Felony Disclosure Form with this application.

(Yes) (No)

5. Has any individual listed in Part 3: Persons of this application ever been convicted ofa felony? If ‘yes’ is selected, that individual must complete and attach the Felony Disclosure Form with this application.

(Yes) (No)

6. Does any individual listed in Part 3: Persons of this application have a pending felonycharge that has not yet received a disposition? If ‘yes’ is selected, that individual must complete and attach the Felony Disclosure Form with this application.

(Yes) (No)

UNLICENSED ACTIVITY Circle One

7. Has the Qualifying Party listed in Part 2 ever received a citation for, or been convictedof, contracting without a license in any state? If ‘yes’ is selected, the Qualifying Party must complete and attach the Unlicensed Activity Disclosure Form with this application.

(Yes) (No)

8. Has any individual listed in Part 3: Persons of this application ever received a citationfor, or been convicted of, contracting without a license in any state? If ‘yes’ is selected, that individual must complete and attach the Unlicensed Activity Disclosure Form with this application.

(Yes) (No)

http://www.roc.az.gov/https://roc.az.gov/sites/default/files/files/RC-L-202A%20-%20Felony%20Disclosure%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202A%20-%20Felony%20Disclosure%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202A%20-%20Felony%20Disclosure%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202A%20-%20Felony%20Disclosure%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202A%20-%20Felony%20Disclosure%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202C%20-%20Unlicensed%20Activity%20Disclosure%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202C%20-%20Unlicensed%20Activity%20Disclosure%20Form.pdf



PART 5: REQUIRED DOCUMENTS Before you submit your application, please review the following checklist. Missing

documents will delay the processing of your application.

Review the License Application and ensure that it contains the following:

Exam Results. The Qualifying Party’s original exam results, or a Completed Waiver Form. Background Checks. Copies of the payment transaction receipt from the background check for

every individual named in Part 3: Persons and the Qualifying Party.

Bond. Completed original Bond Verification Form. Fees. The required application fee, licensing fee and for dual or residential licenses also include

the recovery fund assessment

Government-Issued Identification. The Qualifying Party listed in Part 2, and each individual listed inPart 3: Persons in this License Application must submit a legible copy of a government issuedphoto identification with the application. Acceptable forms of identification include a valid driver’slicense or passport.

Signatures. Completed Signatures section (see next page).

SUPPLEMENTAL DOCUMENTS – Attach the following documents if necessary.

Additional Part 2s: If there is insufficient space to enter all of the required information in Part 2 ofthis application, print out, complete, and attach additional Part 3s to your application.

Additional Part 3s: If there is insufficient space to enter all of the required information in Part 3 ofthis application, print out, complete, and attach additional Part 3s to your application.

License Cancellation Form. If you currently have a license that you wish to cancel upon theissuance of a new license, complete and attach a License Cancellation Form.

Felony Disclosure Forms. If ‘yes’ is selected for any of the Felony Charges questions under, Part 4,attach signed and completed Felony Disclosure Forms and supporting documentation.

Unlicensed Activity Disclosure Forms. If ‘yes’ is selected for any of the Unlicensed Activityquestions under Part 4, attach signed and completed Unlicensed Activity Disclosure Forms anddocumentation of remedial measures.

Solar Warranty. A copy of the solar warranty (if applying for a solar license)

http://www.roc.az.gov/https://roc.az.gov/sites/default/files/files/RC-L-200G%20-%20License%20Waiver%20Request%20Form.pdfhttps://roc.az.gov/background-checkshttps://roc.az.gov/bond-information/https://roc.az.gov/license-feeshttps://roc.az.gov/license-feeshttps://roc.az.gov/sites/default/files/files/RC-L-201A%20-%20License%20Cancellation%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202A%20-%20Felony%20Disclosure%20Form.pdfhttps://roc.az.gov/sites/default/files/files/RC-L-202C%20-%20Unlicensed%20Activity%20Disclosure%20Form.pdf



PART 6: SIGNATURES By signing below, each person certifies that the entire contents of this License Application Form, including all supplementary statements and materials attached, are true and correct, and that this application is not submitted with the intent to evade Chapter 10, Title 32 of the Arizona Revised Statutes. A.R.S. § 32-1154(A)(9). It is a violation of A.R.S. § 32-1154(A)(5) to make a misrepresentation of a material fact in obtaining a license.

Applicant

The authorized representative listed in Part 1: Applicant Information must sign this application.

_____________________ _____________________ ______________ Print Name Signature Date

Qualifying Party The Qualifying Party listed under Part 2: Qualifying Party must sign this application, even if they already signed above.

_____________________ _____________________ ______________ Print Name Signature Date

Persons Every person listed under Part 3: Persons must sign this application, even if they already signed above. If you need additional space for signatures, complete and attach additional signature pages with your application.

_____________________ _____________________ _____________________ Print Name Signature Date






LICENSE BOND

THIS BOND MUST BE ON FILE WITH THE ARIZONA REGISTRAR OF CONTRACTORS

STATE OF ARIZONA REGISTRAR OF CONTRACTORS

BOND NO:

That ______________________________________________________________________________________________________

as the principal, and _______________________________________________________________________________________ (Surety)

a corporation, duly authorized and licensed to transact surety business in the State of Arizona, are held and firmly bound unto the State of Arizona for the benefit of those persons described in A.R.S. §32-1152, as amended, in the penal sum set forth for the classification of license described:

LICENSE CLASSIFICATION PENAL SUM

The Principal has applied to the Registrar of Contractors of the State of Arizona for a license to conduct the business of contracting under the above-described classifications and submits this bond to comply with the provisions of A.R.S. §32-1152, as amended, which are incorporated herein as though fully set forth.

Liability under this bond is limited to the penal sum for each classification of work performed by the principal. Liability under each classification shall be determined strictly in accordance with the provisions of A.R.S. §32-1152, as amended, which are incorporated herein as though fully set forth.

Upon making payment to a claimant against the bond, the Surety shall immediately give written notice to the Principal and the Registrar of Contractors of the date and amount of payment.

The amount of this bond is based on the representation of the Principal of the anticipated annual gross volume of work pursuant to Rule R4-9-112.

This bond becomes effective on day of , 20 .

SIGNED, SEALED AND DATED day of , 20 .

By: Signature of Contractor (Principal) Signature Attorney-In-Fact (Must be Notarized)

By: Title of Signer Print or Type Name of Attorney-In-Fact

Subscribed and sworn to before me this ______________

Print or Type Name of Contractor (Principal) day of __________________, 20____________.

THE ORIGINAL BOND MUST BE SIGNED BY THE PRINCIPAL, ATTORNEY-IN-FACT AND THE NOTARY PUBLIC AND BE FILED WITH THE REGISTRAR OF CONTRACTORS AT: 1700 W. Washington St. Ste. 105, PHOENIX, AZ 85007-2812, TO COMPLY WITH A.R.S. § 32-1152 Mail to: P.O. Box 6688, Phoenix, AZ 85005-6688

Notary Public

My Commission Expires:

State of:

County of:

RC-L-220D 7/12

RC-L-200B-License Application-LLC 20200804Rc-l-220D Bond FormSTATE OF ARIZONA Subscribed and sworn to before me this ______________Print or Type Name of Contractor (Principal) day of __________________, 20____________. Notary Public

My Commission Expires: State of:

1 Limited Liability Company Name: 2 Fictitious Trade Name ie DBA if applicable: 3 Authorized Representative s Name: 4 Arizona Corporation Commission File Number: 5 Requested License Classification Description: 6 Business Address No PO Boxes or Private Mail Boxes: City: State: Zip Code: 7 Mailing Address If different than business address: City_2: State_2: Zip Code_2: 8 Phone Number: 9 Email Address: 10 I consent to receive notifications from the Registrar by email at the following email address: 11 I consent to receive notifications from the Registrar by text messaging at the following telephone number: Policy Number: Company Issuing Policy: 2 SelfInsured Employer You Must Submit Documentation Showing Proof of Coverage with this Application: 3 Exemption SingleMember LLC without any employees or 5050 TwoMember LLC without any employees: Group1: Off1 Name as it appears on your government issued ID: 2 TitlePosition: 3 Ownership: 4 Date of Birth MMDDYYYY: 5 Driver s License or Government ID No: 6 Social Security Number: 7 Are you a US Citizen: 8 Residential Address: City_3: State_3: Zip Code_3: 9 Mailing Address If different than residential address: City_4: State_4: Zip Code_4: 10 Phone Number: 11 Email Address: Enter Email Telephone12 I consent to receive notifications from the Registrar by email at the following email address: Enter Email Telephone13 I consent to receive notifications from the Registrar by text messaging at the following telephone number: 1 Business Name of Employer or SelfEmployed: 2 Duration of Experience eg 112007 through 112017: 3 Average Hours Worked Per Week: 4 Positions: 5 Size of Projects Qualifying Party Worked On Square Foot andor Dollar Amount: 6 Description of Qualifying Party s Main Duties: 7 References Name: 8 Reference s Relationship to Qualifying Party eg Coworker Employer Supervisor: 9 References Mailing Address: City_5: State_5: Zip Code_5: 10 References Phone Number: 11 References Email: 1 Business Name of Employer or SelfEmployed_2: 2 Duration of Experience eg 112007 through 112017_2: 3 Average Hours Worked Per Week_2: 4 Positions_2: 5 Size of Projects Qualifying Party Worked On Square Foot andor Dollar Amount_2: 6 Description of Qualifying Party s Main Duties_2: 7 References Name_2: 8 Reference s Relationship to Qualifying Party eg Coworker Employer Supervisor_2: 9 References Mailing Address_2: City_6: State_6: Zip Code_6: 10 References Phone Number_2: 11 References Email_2: 1 Name as it appears on your governmentIssued ID: 2 TitlePosition Member or Manager: 3 Ownership_2: 4 Date of Birth MMDDYYYY_2: 5 Identification No Driver s License or Government ID No: 6 Social Security Number_2: 7 Are you a US Citizen_2: 8 Business or Residential Address: City_7: State_7: Zip Code_7: 9 Mailing Address If different than business or residential address: City_8: State_8: Zip Code_8: 10 Phone Number_2: 11 Email Address_2: Enter Email Telephone12 I consent to receive notifications from the Registrar by email at the following email address_2: Enter Email Telephone13 I consent to receive notifications from the Registrar by text messaging at the following telephone number_2: Check Box2: OffCheck Box3: Off1 Name as it appears on your governmentIssued ID_2: 2 TitlePosition Member or Manager_2: 3 Ownership_3: 4 Date of Birth MMDDYYYY_3: 5 Identification No Driver s License or Government ID No_2: 6 Social Security Number_3: 7 Are you a US Citizen_3: 8 Business or Residential Address_2: City_9: State_9: Zip Code_9: 9 Mailing Address If different than business or residential address_2: City_10: State_10: Zip Code_10: 10 Phone Number_3: 11 Email Address_3: Enter Email Telephone12 I consent to receive notifications from the Registrar by email at the following email address_3: Enter Email Telephone13 I consent to receive notifications from the Registrar by text messaging at the following telephone number_3: 1 Name as it appears on your governmentIssued ID_3: 2 TitlePosition Member or Manager_3: 3 Ownership_4: 4 Date of Birth MMDDYYYY_4: 5 Identification No Driver s License or Government ID No_3: 6 Social Security Number_4: 7 Are you a US Citizen_4: 8 Business or Residential Address_3: City_11: State_11: Zip Code_11: 9 Mailing Address If different than business or residential address_3: City_12: State_12: Zip Code_12: 10 Phone Number_4: 11 Email Address_4: Enter Email Telephone12 I consent to receive notifications from the Registrar by email at the following email address_4: 13 I consent to receive notifications from the Registrar by text messaging at the following telephone number: 1 Name as it appears on your governmentIssued ID_4: 2 TitlePosition Member or Manager_4: 3 Ownership_5: 4 Date of Birth MMDDYYYY_5: 5 Identification No Driver s License or Government ID No_4: 6 Social Security Number_5: 7 Are you a US Citizen_5: 8 Business or Residential Address_4: City_13: State_13: Zip Code_13: 9 Mailing Address If different than business or residential address_4: City_14: State_14: Zip Code_14: 10 Phone Number_5: 11 Email Address_5: Enter Email Telephone12 I consent to receive notifications from the Registrar by email at the following email address_5: Enter Email Telephone13 I consent to receive notifications from the Registrar by text messaging at the following telephone number_4: 1 Name as it appears on your governmentIssued ID_5: 2 TitlePosition Member or Manager_5: 3 Ownership_6: 4 Date of Birth MMDDYYYY_6: 5 Identification No Driver s License or Government ID No_5: 6 Social Security Number_6: 7 Are you a US Citizen_6: 8 Business or Residential Address_5: City_15: State_15: Zip Code_15: 9 Mailing Address If different than business or residential address_5: City_16: State_16: Zip Code_16: 10 Phone Number_6: 11 Email Address_6: Enter Email Telephone12 I consent to receive notifications from the Registrar by email at the following email address_6: Enter Email Telephone13 I consent to receive notifications from the Registrar by text messaging at the following telephone number_5: Check Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffPrint Name: Date: Print Name_2: Date_2: Print Name_3: Print Name_4: Print Name_5: Print Name_6: Print Name_7: Date_3: Date_4: Date_5: Date_6: Date_7: BOND NO: That: as the principal and: LICENSE CLASSIFICATION 1: LICENSE CLASSIFICATION 2: LICENSE CLASSIFICATION 3: PENAL SUM 1: PENAL SUM 2: PENAL SUM 3: This bond becomes effective on: day of: 20: SIGNED SEALED AND DATED: day of_2: Title of Signer: Print or Type Name of Contractor Principal: 20_2: By_2: Subscribed and sworn to before me this: day of 1: day of 2: 20_3: My Commission Expires: State of: County of: