DOUGLAS A. DUCEY
GOVERNOR
JUDY LOWE
COMMISSIONER
COM-200 rev 6-11-2018
Arizona Department of Real Estate (ADRE)
Enforcement & Compliance Division
www.azre.gov
100 North 15
th
Avenue, Suite 201, Phoenix, Arizona 85007
COMPLIANCE - PROOF OF ATTENDANCE AT SUPPORT GROUP
(Signed by Support Group Leader)(COM-200)
Licensee Name ___________________________ License #_________________
Print Name of Respondent
Consent Order Number: ___________________________ Consent Order dated _____________________
i.e. = year F-DI-000 Commissioner’s Signature Date
This serves as proof of attendance at Support Group m
eetings as verified below. RESPONDENT MUST MAINTAIN
THE ORIGINAL OF THIS FORM FOR 5 YEARS.
SUPPORT GROUP LEADER STATEMENT
The a
bove named individual participated in a Support Group led by me on the date indicated.
__________
_ ______________________________ _________________________
Date Print Name of Support Group Leader Signature of Support Group Leader
_______________ _________________________________________ ___________________________________
Date Print Name of Support Group Leader Signature of Support Group Leader
_____
__________ _________________________________________ ___________________________________
Date Print Name of Support Group Leader Signature of Support Group Leader
_____
__________ _________________________________________ ____________________________________
Date Print Name of Support Group Leader Signature of Support Group Leader
_____
__________ _________________________________________ ____________________________________
Date Print Name of Support Group Leader Signature of Support Group Leader
_____
__________ _________________________________________ ____________________________________
Date Print Name of Support Group Leader Signature of Support Group Leader
ATTAC
H THIS TO COMPLIANCE AFFADAVIT “SUPPORT GROUP CONFIRMATION” FORM COM-201
*For more information or questions visit www.azre.gov
