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Section II: Certification of Grades and Licensure

Instructions to Licensing Authority: The properly authorized officer of the jurisdiction in which the sections of the examination were passed must

complete Part A and B, sign and date the certification and return this form directly to the Office of the Professions at the address at the end of the form.

This form will not be accepted if returned by the applicant. A complete history of the applicant's examination sittings, by section, is essential. (If the

reported grade is different from an initial grade, indicate by asterisk and explain below the reason for change in grade.)

Part A – Certification of Examination Grades

 Not applicable. Applicant did not sit for the examination in this jurisdiction.

This is to certify that ___________________________________________________________________ sat ________________ times for the

(Applicant Name, Section I, Item 3)

certified public accountancy examination(s) in the State of ______________________________________ . The grades were as follows:

Auditing

Bus Law/Prof Res

Accounting & Reporting

Paper Pencil

Financial Accounting &

Business Environment &

Reporting

Auditing & Attestation

Regulation

CBT

Concepts

Date and Grade

The applicant has been credited with the examination section(s) of ___________________________________________ in this State. If there is a

reason why you would not recommend the New York State Board give consideration to acceptance of these grades, please explain:

_____________________________________________________________________________________________________________________

The above grades are recorded as a result of this applicant having passed a written examination: (check one of the following)

Prepared and graded by the American Institute of Certified Public Accountants.

Prepared and graded by this licensing authority.

Prepared by the American Institute of Certified Public Accountants and graded by this licensing authority.

Prepared and graded by the American Institute of Certified Public Accountants but regraded by this licensing authority.

Other (describe)

Our passing grade is ______________%

 Not applicable. Applicant is not licensed in this jurisdiction.

Part B – Certification of Licensure

The applicant holds: (check one)

an original license

A license issued by endorsement or reciprocity

License Number: ________________________________________ Date issued: _______ / _______ / _______

day

yr.

Is the applicant currently registered to practice?

Yes

Was there ever any disciplinary action against this license?

Yes

If yes, please explain ______________________________________________________________________________________________________

Are there any disciplinary charges pending against this license?

Yes

If yes, please explain ______________________________________________________________________________________________________

Certification

I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named on this form. I further certify that,

other than those listed above, this licensing authority has never taken any disciplinary action against this person and that, in so far as the licensing

authority has knowledge, there have been no charges preferred nor has any information been presented relating to any question of unprofessional or

immoral conduct except as noted in Part B, questions 2 and 3.

Signature: ___________________________________________________________________

Date: _______ / _______ / _______

day

yr.

Print name: __________________________________________________________________

Name of licensing authority: ____________________________________________________

(SEAL OF LICENSING

Title or official position: ________________________________________________________

AUTHORITY)

Telephone: _______________________________ Fax: _______________________________