Application Form For Certificate By Passing Examination In Kansas
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1(REV. 07/16)
STATE OF KANSAS
PRINT OR TYPE
BOARD OF ACCOUNTANCY
900 SW JACKSON, SUITE 556S
Date of Birth:_________________
TOPEKA, KS
66612-1239
Sex:____
Race:_______________
TELEPHONE:
(785) 296-2162
APPLICATION FOR CERTIFIED PUBLIC ACCOUNTANCY CERTIFICATE BY PASSING EXAM IN KANSAS
INSTRUCTIONS:
APPLICATIONS FOR CPA CERTIFICATES MUST BE FILED WITH THE BOARD AT THE ABOVE ADDRESS ON THIS FORM.
VERIFICATION OF SATISFACTORY COMPLETION OF THE AICPA ETHICS COURSE IS REQUIRED FOR CERTIFICATION IN KANSAS.
YOUR SIGNATURE ON THE ENCLOSED OATH MUST BE WITNESSED BY A CPA, AND RETURNED TO THE BOARD OFFICE.
(NOTE: ANYONE WHO INITIALLY SAT FOR THE EXAM BEGINNING MAY 1997, AND THEREAFTER, MUST SUBMIT A NON-REFUNDABLE $25 CERTIFICATE FEE.)
(DO NOT DETACH)
-----------------------------------------------------------------------------------------
PRINT
SOCIAL
1.
NAME___________________________________
2.
SECURITY NO.__________________________
(AS YOU WANT IT TO APPEAR ON YOUR CPA CERTIFICATE)
PURSUANT TO 5 U.S.C. 552a, THE KANSAS BOARD OF ACCOUNTANCY ADVISES YOU THAT SOCIAL SECURITY NUMBERS PROVIDED TO
THE BOARD, PURSUANT TO K.S.A. 74-148 AND 74-139, MAY BE PROVIDED TO THE KANSAS DEPARTMENT OF REVENUE, UPON
REQUEST, OR MAY BE USED FOR CHILD SUPPORT ENFORCEMENT PURPOSES.
3.
NAME WHEN YOU PASSED CPA EXAM (IF DIFFERENT FROM ABOVE)_____________________________
(PLEASE SEND A COPY OF THE LEGAL DOCUMENTATION FOR ANY NAME CHANGE.)
4.
CURRENT EMPLOYER____________________________________________________________________
5.
TITLE_______________________________________________________________________________
6.
ADDRESSES:
BUSINESS________________________________________________________________
(STREET/P.O. BOX
(CITY)
(ST)
(ZIP CODE+4)
RESIDENCE___________________________________________________________________________
(STREET/P.O. BOX)
(CITY)
(ST)
(ZIP CODE+4)
7.
PREFERRED MAILING ADDRESS:
BUSINESS
RESIDENCE
8.
PREFERRED EMAIL ADDRESS:_____________________________________BUSINESS
PERSONAL
9.
TELEPHONES: BUSINESS________________
FAX________________
RESIDENCE________________
10.
EXAM DATE PASSED FINAL SECTION OF CPA EXAM UNDER KANSAS LAW_________________________
11.
HAVE YOU EVER BEEN ACCUSED OR CONVICTED OF ANY CRIME, MISDEMEANOR, OR FELONY, UNDER THE LAWS OF ANY
STATE, OR THE UNITED STATES?
(IF YES, PLEASE PROVIDE A FULL EXPLANATION.)
YES
NO
12.
HAVE YOU FAMILIARIZED YOURSELF WITH THE BOARD’S CODE OF PROFESSIONAL ETHICS,
AND DO YOU AGREE TO ABIDE BY SAID CODE?
YES
NO
13.
HAVE YOU
ATTACHED
VERIFICATION OF COMPLETION
OF THE
AICPA CORRESPONDENCE
ETHICS COURSE EXAM?
YES
NO
A.
IF NO, WILL VERIFICATION BE SENT DIRECT FROM AICPA?
YES
NO
B.
IF NO TO BOTH QUESTIONS ABOVE, WHEN CAN WE EXPECT TO RECEIVE IT?__________
14.
ARE YOU PERFORMING ANY PUBLIC ACCOUNTING SERVICES FOR KANSAS CLIENTS?
YES
NO
IF SO, WHAT TYPE OF SERVICES ARE YOU PERFORMING?___________________________________
15.
WITHIN THE LAST SEVEN YEARS, HAVE YOU BEEN DELINQUENT IN FILING YOUR TAX RETURNS?
(IF YES, PLEASE ATTACH A FULL EXPLANATION.)
YES
NO
16.
WITHIN THE LAST SEVEN YEARS, HAVE YOU BEEN DELINQUENT IN FILING TAX RETURNS AND/OR PAYING TAXES
COLLECTED ON BEHALF OF OTHERS FOR WHICH YOU WERE RESPONSIBLE? (I.E., WITHHOLDING TAXES,
SALES TAX, USE TAX, ETC.
NOTE: ENTERING INTO A PAYMENT PLAN DOES NOT MEAN YOU ARE CURRENT.)
(IF YES, PLEASE ATTACH A FULL EXPLANATION.)
YES
NO
NOTE: IF YOU ARE PERFORMING ANY PUBLIC ACCOUNTING SERVICES IN KANSAS,
OR PLAN TO DO SO IN THE FUTURE, YOU ARE
YOU ARE REQUIRED TO OBTAIN A PERMIT (LICENSE)
TO PRACTICE
AS SOON AS YOU ARE ELIGIBLE, AND BEFORE YOU MAY USE
THE
CPA
DESIGNATION
WITH YOUR NAME. PLEASE REFER TO K.S.A. 1-302, 1-310 AND K.A.R. 74-5-2(g). APPLICATIONS
PENDING FOR 120 DAYS FROM THE DATE OF RECEIPT WILL BE CANCELLED AND ALL FEES FOREFEITED.
FORM OF PAYMENT:
CHECK
CREDIT CARD
Credit Card: VISA
MASTERCARD
AMERICAN EXPRESS
DISCOVER
CREDIT CARD #________ ________ ________ ________
EXP. DATE (MO/YR) ________ ________
________________________________________________
NOTE: IF USING A BUSINESS CREDIT CARD, PLEASE PROVIDE THE VERIFICATION
CARDHOLDER’S SIGNATURE
CODE FOUND ON THE BACK OF THE CREDIT CARD. ____________
I HEREBY CERTIFY THAT ALL OF THE ABOVE STATEMENTS MADE BY ME ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
DATE_______________
SIGNATURE____________________________________________________________________
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