Form 3 - Certification Of Out-Of-State Licensure And Examination Grades - The State Education Department, The University Of The State Of New York
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1
2Certified Public Accountant
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Form 3
Office of the Professions
Division of Professional Licensing Services
Certification of Out-Of-State Licensure and Examination Grades
(Complete this form to transfer out-of-state licensure or examination grades)
Applicant Instructions
1.
Complete Section I in ink. In item 3, enter your name exactly as it appears on your Application For Licensure (Form 1). Be sure to sign and date item 8.
2.
Send this form to the appropriate jurisdiction that will provide the certification of examination scores and ask that they complete Section II and forward
this form to the Office of the Professions at the address at the end of the form. Be sure to include any fee required. This form will not be accepted if
submitted by the applicant.
3.
Endorsement and Foreign endorsement applicants must provide a certification of the license they are endorsing. You may do this by submitting this form
or a print-out from the other jurisdiction's on-line verification system or CPA Verify.
Section I: Applicant Information
1
2
Social Security Number
Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Full Name Exactly as it Appears on Your Application for Licensure (Form 1)
5
Telephone/E-Mail Address
Last
Daytime Phone
First
Area Code
Phone Number
Middle
E-Mail Address (Please print clearly)
4
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
Name as it appears on the U.S. CPA Examination (if different from above):
Last ___________________________________________ First _____________________________________ Middle _______________________
7
If licensed by examination in the United States, give jurisdiction: ___________________________________________________________________
8
To the licensing authority of: ________________________________________________________________________________________________
Check appropriate boxes:
I hereby make application for the transfer of Uniform CPA Examination grades and related information.
I am a licensed certified public accountant of your jurisdiction.
License number: __________________________________________ Date issued: _______ / _______ / _______
mo.
day
yr.
I request and give permission to the licensing authority named above to complete the information on this form and send any documentation requested,
including that requested on this form, to the New York State Education Department.
Signature: ____________________________________________________________________________
Date: _______ / _______ / _______
mo.
day
yr.
Licensing Authority of the Certifying Jurisdiction Must Complete Section II
Rev. 6/16
Form 3, Page 1 of 2
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