Form 49209 - Accountancy Application - Indiana Professional Licensing Agency
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5Indiana Professional Licensing Agency
ACCOUNTANCY APPLICATION, FORM #1
302 W. Washington St., Room E034
State Form 49209 (R/8-99)
Indianapolis, Indiana 46204
Approved by State Board of Accounts, 1999
(317) 232-2980
The reverse side of this form lists the requirements for each type of application filed.
All information will be verified. Make checks payable to Indiana Board of Accountancy.
GENERAL INFORMATION
Please check one:
CPA certificate
AP certificate
Reciprocity certificate
Transfer of grades
Telephone number (home)
Telephone number (business)
Date of birth (month, day, year)
Date (month, day, year)
* This agency is requesting the disclosure of your Social Security number in accordance with IC 4-1-8-1. Disclosure
Social Security number *
is mandatory; this record cannot be processed without it.
Name of applicant (last, first, middle)
Address (number and street, city, state, ZIP code)
Mailing address (number and street, city, state, ZIP code)
Have you ever been convicted of:
A. An act which would constitute a ground for disciplinary sanction under IC 24-2-1-13.1 (b)
Yes
No
B. A felony that has a direct bearing on your ability to practice competently
Yes
No
If yes, please attach supporting documentation relevant to the conviction.
Date you passed the CPA examination (month, day, year)
Name of state in which you passed the examination
If yes, state where issued
Date issued
Do you hold a license in good standing as a certified public accountant from a
License number
state other than Indiana?
Yes
No
Are you an employee of a certified public accountant practicing in Indiana?
If yes, give name and address of employer
Yes
No
NOTARY CERTIFICATE
STATE OF ________________________________________________
SS:
COUNTY OF_______________________________________________
I, ______________________________________________________, first being duly sworn on oath, say that I am the above named, that I have personally
prepared the foregoing application and all attachments, and that the same is true to the best of my knowledge and belief.
Signature of Notary Public
Signature of applicant
Printed or typed name of applicant
Printed or typed name of Notary Public
County of residence
Date subscribed and sworn to (Notary Public)
Date Commission expires
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