Fill and Sign the Arizona Joint Tax Application Business Taxes Registration Application Online Tax ID Number Form

STATE OF CALIFORNIA BUSINESS TRANSPORTATION AND HOUSING AGENCY DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT DIVISION OF CODES AND STANDARDS OCCUPATIONAL LICENSING PROGRAM APPLICATION FOR OCCUPATIONAL LICENSE CHANGE, CORRECTION OR REPLACEMENT SECTION 1 – PURPOSE OF APPLICATION CHECK THE APPROPRIATE BOX(ES) TO INDICATE THE PURPOSE OF THE APPLICATION SUBMITTAL AND FOLLOW THE INSTRUCTIONS PROVIDED. LICENSEE PERSONAL NAME CHANGE (Complete Sections 2 and 8. Salesperson: Attach old license and pay fee of $45*.) LICENSEE CHANGE OF RESIDENCE (Complete Sections 3 and 8. Salesperson: Attach old license and pay fee of $45*.) SALESPERSON TERMINATION (Dealer: Complete Section 4 and return license to salesperson. No fee required.) SALESPERSON EMPLOYMENT CHANGE (Dealer: Complete Section 5; Salesperson: Complete Sections 7 and 8: Attach old license and pay fee of $45*.) BUSINESS NAME, DOING BUSINESS AS (DBA) NAME OR MAILING ADDRESS CHANGE (Complete Sections 6 and 8: Attach old license(s) and pay fee of $45*.) REPLACEMENT LICENSE (Complete Sections 7 and 8: Attach old license, if available, and pay fee of $45*.) NOTE: COMPLETE SECTION 9 IF THE OLD LICENSE IS NOT ATTACHED WHEN REQUIRED. *This application shall be accompanied by the appropriate fees in accordance with the California Code of Regulations, Title 25, Division 1, Chapter 4, Subchapter 1, Article 3, Section 5040. Submittals for multiple changes to the same license require only one fee. SECTION 2 – LICENSEE NAME CHANGE (Type or Print) LICENSE NUMBER: ___________________________________________ EFFECTIVE DATE: _______________________________ NEW NAME: __________________________________________________________________________________________________ First Middle Last FORMER NAME: __________________________________________________________________________________________________________ First Middle SECTION 3 – LICENSEE CHANGE OF RESIDENCE Last (Type or Print) LICENSE NUMBER: ___________________________________________________ EFFECTIVE DATE: _________________________________ NAME: _______________________________________________________________ TELEPHONE NUMBER: (____) ________________________ First Last NEW RESIDENCE ADDRESS: _______________________________________________________________________________________________ Number and Street City State ZIP Code MAILING ADDRESS (If different): _____________________________________________________________________________________________ Number and Street or P.O. Box SECTION 4 – SALESPERSON TERMINATION City ZIP Code (Type or Print) SALESPERSON’S LICENSE NUMBER: _________________________________________ SALESPERSON’S NAME: State EFFECTIVE DATE: ____________________________ _______________________________________________________________________________ First Middle Last DEALERSHIP (DBA) NAME: _________________________________________________________________________________________________ DEALER’S NAME: ______________________________________________________DEALER LICENSE NUMBER: __________________________ First Last DEALER’S SIGNATURE ________________________________________________________________________________ TITLE ________________________________________________________________ SECTION 5 – SALESPERSON EMPLOYMENT CHANGE (Type or Print) SALESPERSON’S LICENSE NUMBER: _________________________________________ SALESPERSON’S NAME: DATE ______________________________ EFFECTIVE DATE: ____________________________ _______________________________________________________________________________ First Middle Last DEALERSHIP (DBA) NAME: _________________________________________________________________________________________________ DEALER’S NAME: ______________________________________________________DEALER LICENSE NUMBER: __________________________ First DEALER’S SIGNATURE Last ________________________________________________________________________________ TITLE ________________________________________________________________ HCD OL 18 (Rev. 06/09) Page 1 of 2 DATE ______________________________ SECTION 6 – BUSINESS NAME, DBA NAME OR MAILING ADDRESS CHANGE (Type or Print) EFFECTIVE DATE: ____________________ Check appropriate box Individual Partnership* Limited Liability Company (LLC)* Corporation* * Attach: California Secretary of State (SOS) endorsed (filed) copies of corporate, LLC or partnership amendments, or certified SOS documents that show the change(s), such as a certificate of amendment for a corporation, LLC or partnership. New or changed DBA names require written approval from the local issuing government agency. Note: Currently, SOS filings are not mandatory for General Partnerships (GP) therefore until there is a change in law, GP’s who have not filed with the SOS, may attach properly signed partnership amendments showing the requested change(s). NEW BUSINESS NAME (If applicable): _______________________________________ EFFECTIVE DATE: _________________ FORMER BUSINESS NAME (If applicable): ______________________________________________________________________________________ NEW DBA NAME (If applicable): ___________________________________________ EFFECTIVE DATE: _________________ FORMER DBA NAME (If applicable): _________________________________________________________________________ PLACE OF BUSINESS ADDRESS: _________________________________________________________________________ Number and Street NEW MAILING ADDRESS (If applicable): City State ZIP Code ______________________________________________________________________ Number and Street or P. O. Box City State ZIP Code TELEPHONE NUMBER: (____) _____________________________ E-MAIL ADDRESS (If applicable): ______________________________________ SECTION 7 – REPLACEMENT LICENSE (Type or Print) LICENSEE NAME: ___________________________________________________________ LICENSE NUMBER: ____________________________ ADDRESS: _________________________________________________________________ LICENSE TYPE: _______________________________ MAILING ADDRESS (If different): ___________________________________________________________________________ REPLACEMENT IS DUE TO: Check appropriate box LOSS MUTILATION ERROR NEW EMPLOYING DEALER IF ERROR, EXPLAIN _______________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ SECTION 8 – APPLICANT CERTIFICATION I, ___________________________________________________________________________ , certify under penalty Type or Print First and Last Name of perjury under the laws of the State of California that the information contained herein is true and correct to the best of my belief. Signature ____________________________________________________________ Date ______________________ SECTION 9 – STATEMENT OF FACTS I, ________________________________________________________________ , the undersigned, hereby declare that Type or Print First and Last Name I am unable to surrender the license required to be returned with this Application for Occupational License Change, Correction or Replacement because: __________________________________________________________________ ________________________________________________________________________________________________________________________ I further acknowledge that said license remains the property of the Department of Housing and Community Development. Should this license be located or come into my possession at a later date, I will surrender it to the nearest Department of Housing and Community Development Office. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. SIGNATURE _____________________________________________________________________________________ EXECUTED IN THE COUNTY OF _______________________________________ STATE OF ___________________ HCD OL 18 (Rev. 06/09) Page 2 of 2