Application For Certified Public Accountant (Cpa) License - California
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3APPLICATION FOR CERTIFIED PUBLIC ACCOUNTANT (CPA) LICENSE
APPLICATION PROCESSING FEE $250
SECTION I – APPLICANT TYPE
____ A. I passed the CPA Exam as a California candidate and I have not been
issued a valid license in any state (exclude Section III).
CPA Exam Unique ID#____________ Date CPA Exam Passed____________
In this space, glue a recent
____ B. I passed the CPA Exam as a candidate of a state other than California, and
2” x 2” passport size and
I have not been issued a valid license in any state (exclude Section III).
quality photograph
Date CPA Exam Passed____________ State____________
showing only your head
____ C. I have been issued a valid license to practice public accounting in a state
and shoulders
other than California.
____ D. I was once licensed in California. My CPA certificate was canceled due to
nonpayment of fees (exclude Section III).
□
□
Certificate #______________ Experience type:
General
Attest
____ E. I passed the CAQEX/IQEX examination (exclude Section III).
DO NOT WRITE IN THIS SPACE
SECTION II – PERSONAL INFORMATION
License No.________________
1.
Full Name (no initials)_________________________________________________
Last
Date Issued_________________
___________________________________________________________________
First
Middle
2.
List other name(s) known by ___________________________________________
3.
Residence address___________________________________________________________________________________
Number and Street
City
State
Zip Code
If you do not want your residence address available to the public, please provide an alternative address of record below.
__________________________________________________________________________________________________
Number and Street
City
State
Zip Code
4.
Telephone # (________)____________________________
(________)______________________________
Personal
Business
5.
Email address (optional) ______________________________________________________________________________
6.
U.S. Social Security/Individual Taxpayer Identification #_________________________ 7. Birthdate_________________
□
□
8.
a.
Are you currently serving in or have you previously served in the U.S. Military?
(check one)
Yes
No
□
□
b.
Did you previously serve in the U.S. Military and receive an honorable discharge?
(check one)
Yes
No
c.
Are you married to, or in a domestic partnership or other legal union with, an active duty member of the U.S. Military
□
□
who is assigned to a duty station in this state under official active duty military orders? (check one)
Yes
No
IF THE ANSWER TO QUESTION 8B OR 8C IS “YES,” PROVIDE EVIDENCE OF HONORABLE DISCHARGE (DD FORM 214),
OR EVIDENCE OF LEGAL UNION AND YOUR SPOUSE OR PARTNER’S MILITARY DUTY
9.
Current employer’s name and address __________________________________________________________________
_________________________________________________________________________________________
Number and Street
City
State
Zip Code
11A-5 (Rev. 7/16)
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