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Form 08-4178 - Cpa Limited Liability Company (Llc) Registration And Permit To Practice Page 3

ALASKA STATE BOARD OF PUBLIC ACCOUNTANCY

AUTHORIZATION FOR INTERSTATE EXCHANGE OF LICENSURE INFORMATION

This form is essential to the application you are filing with this board. If you are a nonresident Limited Liability Company,

please have the state in which you established original licensure as a LLC complete this form. You are advised to check

with that board before forwarding this form to determine if there are additional requirements to be met before the

information will be released.

SECTION A – TO BE COMPLETED BY THE APPLICANT (Please type or print legibly)

Name of Limited Liability Company:

Mailing Address:

Street/P.O. Box Number

City

State

ZIP Code

Daytime Telephone Number:

I hereby request and authorize the

to provide any

and all pertinent information requested in this form to the Alaska State Board of Public Accountancy to complete an

application filed with that agency.

Signature

Date Signed

SECTION B – LICENSE/PERMIT TO PRACTICE PUBLIC ACCOUNTING

The LLC identified in Section A of this form holds a license/permit issued by this board on

which remains valid until

and is currently in good standing in this state. (Please note any

exceptions to the above statement in Section D of this form.)

License Number:

Issue Date:

Expiration Date:

License Status:

Current o

Lapsed o

Pending Litigation o

Suspended o

Revoked o

o Yes

o No

Have licensee, partners and/or shareholders met the continuing education requirement?

Number of hours per year:

SECTION C – ADDITIONAL INFORMATION

SECTION D – EXCEPTIONS OR EXPLANATIONS OF INFORMATION PROVIDED

The information provided herein is correct to the best of our knowledge.

Board

OFFICIAL BOARD SEAL

Please return this form to:

Board Official Signature

Department of Community and

Economic Development

Alaska State Board of Public Accountancy

Title

P.O. Box 110806

Juneau, Alaska 99811-0806

(907) 465-3811

Date

08-4178a (Rev. 9/00)

Form 08-4178 - Cpa Limited Liability Company (Llc) Registration And Permit To Practice Page 3

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