Application Form For Kansas Certified Public Accountant Certificate By Transfer Of Grades (Page 2 of 2) in pdf

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Date of Birth:________________

APPLICATION FOR KANSAS CERTIFIED PUBLIC ACCOUNTANT

Sex:______

Race:____________

CERTIFICATE BY TRANSFER OF GRADES

1. FULL NAME (Indicate if different when certified):__________________________________________________________________________________

(If name change has occurred, please submit a copy of the legal documentation verifying name change.)

NAME CERTIFICATE TO BE ISSUED UNDER (If different than above):_______________________________________________________________

SOCIAL SECURITY NUMBER_______________________________________________________

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.

2. NAME OF PRESENT EMPLOYER:_____________________________________________________________________________________________

3. TITLE:___________________________________________________________________________________________________________________

4. FULL BUSINESS ADDRESS:_________________________________________________________________________________________________

5. RESIDENCE ADDRESS:_____________________________________________________________________________________________________

PREFERRED MAILING ADDRESS:

BUSINESS

RESIDENCE

6. PREFERRED EMAIL ADDRESS:_______________________________________________ BUSINESS

PERSONAL

7. TELEPHONES: RESIDENCE__________________________

BUSINESS__________________________

FAX__________________________

8. ORIGINAL CPA CERTIFICATE NO.:_______________________

CURRENT PERMIT VALID UNTIL:__________________________________

FROM THE STATE OF: _________________________________

STATE CPA EXAM COMPLETED IN:________________________________

ISSUED ON DATE OF:__________________________________

OTHER STATES CERTIFIED IN:____________________________________

9. ARE YOU PRESENTLY PERFORMING, OR DO YOU PLAN TO PERFORM (CIRCLE ONE) ANY PUBLIC ACCOUNTING SERVICES, EITHER AS AN EMPLOYEE

OR AN OWNER, FOR KANSAS CLIENTS?

YES

IF YES, WHAT TYPE OF SERVICES ARE YOU, OR WILL YOU BE PERFORMING?_______________________________________________

10. IF ANSWER TO QUESTION 9 IS YES, IS PUBLIC ACCOUNTING YOUR PRINCIPAL OCCUPATION?

YES

11. DO YOU HAVE ONE YEAR OF EXPERIENCE IN PUBLIC ACCOUNTING, GOVERNMENT, INDUSTRY OR ACADEMIA THAT CAN BE VERIFIED BY

A LICENSED CPA?

YES

12. HAVE YOU EVER BEEN ACCUSED OR CONVICTED OF ANY CRIME, MISDEMEANOR OR FELONY, UNDER THE LAWS OF ANY STATE, OR THE UNITED

STATES, OR BEEN THE OBJECT OF ANY CIVIL SUIT BASED UPON ALLEGATIONS OF NEGLIGENCE, INCOMPETENCE, MISCONDUCT,

FRAUD OR DECEIT IN THE PRACTICE OF PUBLIC ACCOUNTING, UNDER THE LAWS OF ANY STATE, OR OF THE UNITED STATES?

(If yes, attach full explanation.)

YES

13. HAVE YOU EVER HAD A CPA CERTIFICATE OR LICENSE TO PRACTICE FROM ANY OTHER STATE CANCELED, REVOKED, SUSPENDED OR

VOLUNTARILY SURRENDERED? (IF YES, ATTACH A FULL EXPLANATION.)

YES

14. HAVE YOU EVER HAD THE RIGHT TO PRACTICE BEFORE THE UNITED STATES TREASURY DEPARTMENT, OR ANY OTHER GOVERNMENT

BODY OR AGENCY CANCELED OR REVOKED? (IF YES, ATTACH A FULL EXPLANATION.)

YES

15. WITHIN THE LAST SEVEN YEARS, HAVE YOU BEEN DELINQUENT IN FILING YOUR TAX RETURNS?

YES

(IF YES, PLEASE ATTACH A FULL EXPLANATION.)

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

17. HAVE YOU ATTACHED THE REQUIRED NON-REFUNDABLE FEE OF $250?

YES

APPLICATIONS PENDING FOR 120 DAYS FROM DATE OF RECEIPT WILL BE CANCELLED AND ALL FEES FORFEITED.

Credit Card: VISA

MASTERCARD

AMERICAN EXPRESS

DISCOVER

CREDIT CARD #________ ________ ________ ________

EXP. DATE (MO/YR) ________ ________

________________________________________________

NOTE: IF USING A BUSINESS CREDIT CARD, PLEASE PROVIDE THE

CARDHOLDER’S SIGNATURE

VERIFICATION CODE FOUND ON THE BACK OF THE CREDIT CARD. ________

I hereby certify that the foregoing statements provided by me are true and correct to the best of my knowledge, and that I have not omitted or suppressed any

information which might have an affect on my application. I also certify that I have read and understand the Kansas Statutes and the Kansas Board’s Regulations,

including the Code of Professional Ethical Conduct, and agree to comply with same if my application for a Kansas CPA certificate is approved.

DATE___________________

SIGNATURE_______________________________________________________________________________________