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NEBRASKA BOARD OF PUBLIC ACCOUNTANCY

P.O. Box 94725, Lincoln, NE 68509-4725

(402) 471-3595 or (800) 564-6111

e-mail: Dan.Sweetwood@nebraska.gov Fax: (402) 471-4484

APPLICATION FOR FIRM PERMIT

FOR SOLE PROPRIETOR

CURRENT PERMITS EXPIRE JUNE 30. Deadline for reapplying is May 31.

If you are no longer practicing public accountancy as a sole proprietor, check this box, write in date closed, and

return this form to the Board's office. 

Date closed: _____/_____/_______

Applications must be completed, signed and returned by Sole Proprietor, and have an original signature.

Complete the following

Incomplete applications will be returned unprocessed and deemed not to have been received.

information.

Firm: ________________________________________

Owner: _______________________________________

Owner Certificate #:__________________

Address: ______________________________________

______________________________________

Phone: ____________________________

Fax #:____________________________

E-mail:_______________________________

(Note: If you are practicing as another type of firm entity in Nebraska, you must contact the Board's office for

the appropriate forms and information. DO NOT send in this form - this form is for a sole proprietorship firm

permit only, and to register the firm's office and work space locations.)

How many full-time, permanent employees are employed by the firm?_________________

DISCLOSURE STATEMENTS

1. In the last year, has your firm had any application for licensure denied, or any professional or vocational license

revoked or suspended, or has your firm signed any stipulation or consent order or agreement with a state or federal

agency, or been subject to any investigative or other disciplinary action regarding such a license in this state or any other

state or by the Federal government?



No.



Yes; Attached are details regarding type of license, name and location of licensing agency, violation charged,

action taken (including stipulation and consent orders), effective date of sanction, and any other pertinent

information.

2. In the last year, have you or your firm been named in a lawsuit as a defendant with respect to lawsuits involving you

or your Nebraska practice, regardless of where the lawsuit was filed?



No.



Yes. Attached are details regarding date of filing of lawsuit, name and location of the court, summary of

allegations, disposition of the lawsuit or status if still pending, and any other pertinent information.

State Board Use Only (4/14)

Date Recd.______________

Check #__________

Receipt # Issued for Office Registration:_______________

Code: 13-7511

Amount: $_____________

Application For Firm Permit For Sole Proprietor Form - Nebraska Board Of Public Accountancy

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