Program Qualification Form - State Of Nebraska Board Of Public Accountancy

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STATE OF NEBRASKA
BOARD OF PUBLIC ACCOUNTANCY
P.O. Box 94725, Lincoln, NE 68509
Program Qualification Form
USE A SEPARATE FORM FOR EACH QUALIFICATION REQUESTED
A. Please answer items 1 through 12:
1. Name of requesting
person/firm:_____________________________________________________________________
Organization of person/firm:_________________________________________________________
Certificate #
____________ E-mail:_________________________________________
(If applicable)
Address:________________________________________________________________________
City: ______________________
State: ________
Zip: ______________
2. C ourse Title:_____________________________________________________________________
3. Requested number of CPE hours of credit:_____________________________________________
Note: Hours should be based on 50-minute hour and must be rounded DOWN to nearest whole number.
4. If all or part of this course contains ethics hours, record the # of hours requested here:_____________
5. Date(s) of course/presentation:______________________________________________________
6. Subject Matter: (Please circle all that apply)
Acct. & Auditing
Tax
Software Training
Management
Investments
Consulting
Personal Development
Fraud Insurance
Medicare/Medicaid
Human Resource
Ethics
Specialized Knowledge
Other: (please specify) _______________
7. Method of Delivery: (Please circle all that apply)
Formal (live)
Web-cast (interactive-formal) Self Study
Web-cast (self-study)
Publication
Instruction/Presentation
College Course
Video-conference
Audio-conference
Tele-conference
Other: (please specify) ____________________
8. Location of Course: _______________________________________________________________
9. Sponsoring Organization: ___________________________________________________________
10. Is the Sponsor registered with NASBA? Registry #
Yes
No
11. Business address of Sponsoring Organization: _________________________________________
_________________________________________
12. Contact Person:_____________________________ Phone #:____________________
13. ATTACH A STATEMENT ON HOW THIS COURSE RELATES TO YOUR PRACTICE OF PUBLIC
ACCOUNTANCY. DESCRIBE HOW THE COURSE CONTRIBUTES TO THE PROFESSIONAL AND
TECHNICAL COMPETANCY OF A CPA IN PUBLIC PRACTICE.
B. You Must Include:
Course outline/syllabus
Course timeline
Name and background of Instructor/Speaker

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