Public Accounting Experience Form - State Of Nebraska Board Of Public Accountancy (Page 2 of 2) in pdf

Public Accounting Experience Form - State Of Nebraska Board Of Public Accountancy Page 2

CERTIFICATE OF PUBLIC ACCOUNTING EXPERIENCE

CERTIFICATION BY APPLICANT:

LEGAL NAME OF APPLICANT _______________________________________________________________

Address __________________________________________________________________________________

(Street)

(City)

(State) (Zip Code)

Telephone #___________________________

Fax #_______________________________________

"I have reviewed the previous page with the hours, dates, CPA and firm information listed regarding my

experience and certify that all information is complete and accurate. I have enclosed the Initial Permit to

Practice application with this form."

___________________________________________________________________________________________________

APPLICANT’s SIGNATURE

DATE

STATE OF ____________________________

)

) ss.

COUNTY OF __________________________

)

Before me, a notary public, in and for the county and state aforesaid, personally appeared ___________________________

known to me to be the person named, who, being duly sworn, deposes and says that the signature hereto is his/her own

signature. Given under my hand, this, the ______ (day) of ______________ (month), ________ (year).

(Seal)

____________________________________________

Notary Public

(11/05)

Page 2 of 2

Public Accounting Experience Form - State Of Nebraska Board Of Public Accountancy Page 2