Form 9069 - Application For Reciprocal Issuance (Certified Public Accountant Certificate) - Indiana Professional Licensing Agency

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APPLICATION FOR RECIPROCAL ISSUANCE
INDIANA BOARD OF ACCOUNTANCY
Indiana Professional Licensing Agency
(Certified Public Accountant Certificate)
302 W. Washington St., Rm. E034
Indianapolis, IN 46204-2700
State Form 9069 (R4 / 7-97)
Approved by the State Board of Accounts, 1997
SOCIAL SECURITY NUMBER
*
Your Social Security number is requested in accor-
dance with IC 4-1-8-1; however disclosure is not
FEE: $50.00
mandatory. The number will be given to the Indiana
Department of Revenue.
LICENSURE REQUIREMENTS
The Indiana Board of Accountancy may issue a certified public accountant certificate without examination to an applicant meeting
the following qualifications:
Applicant must:
1.
Be the holder of a certificate, license or permit issued by another state.
2.
Meet the requirements of IC 25-2.1-4-4 and any other requirements the Board may establish.
PART I - GENERAL
Name of applicant
Residence address (street and number, city, state and ZIP code)
Business address (street and number, city, state and ZIP code)
Mailing address (street and number, city, state and ZIP code)
Telephone number (business)
Date of birth (month, day, year)
Social Security number *
Have you been convicted of:
A. an act which would constitute a ground for
Yes
No
or
B. a felony that has a direct bearing on
Yes
No
disciplinary sanction under IC 25-2-1-13.1(b);
your ability to practice competently?
If Yes, please explain on a separate sheet and attach to this application.
Do you hold a license in good standing as a certified
If Yes, state where issued
Date issued (month, day, year)
License number
public accountant?
Yes
No
Was license issued as a result of an examination by
CERTIFICATION STATUS WILL BE REQUESTED OF THE STATE
the American Institute of Certified Public Accountants?
OF JURISDICTION BY THE INDIANA BOARD OF ACCOUNTANCY.
Yes
No
Are you an employee of a certified public accountant
If Yes, give address
practicing in Indiana?
Yes
No
PART II - EXPERIENCE
Indicate employment or business experience requiring the use of accounting skills. Begin with most recent employment and identify
public accounting experience. Attach supplementary schedule if necessary.
Name of employer
Dates employed (month, day, year)
From:
To:
Address of employer (street and number, city, state and ZIP code)
Duties
Name of employer
Dates employed (month, day, year)
From:
To:
Address of employer (street and number, city, state and ZIP code)
Duties
Name of employer
Dates employed (month, day, year)
From:
To:
Address of employer (street and number, city, state and ZIP code)
Duties
Continued

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