Administrative Change Request Form

2. Permits are not transferable. If this business has a new owner, a new permit application is required- please contact (602) 506-6824 for more information.

4. This form may only be used to change/update an owner mailing address, billing mailing address, or business name.

6. The Permit Owner Name refers to the entity or sole proprietor that owns the establishment. Management Companies may not be listed as the Owner.

10. Business Information

12. Permit Number(s)*

14. Name of Permitted Establishment*

16. Address*

18. City*

19. State*

20. Zip Code*

24. Update / Change

    1. Owner Mailing Address / Contact
    2. Billing Mailing Address / Contact

26. New Mailing Address

28. City

29. State

30. Zip Code

32. Phone Number

33. Email Address

37. Update / Change

    1. Business Name

39. New Business Name

43. Name of Requestor*

44. Title*

46. Phone Number

47. Email Address

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field