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Form 08-4144 - Application For Reinstatement Form - Department Of Community And Economic Development Alaska State Board Of Public Accountancy Division Of Occupational Licensing

CPA

MAIL THIS FORM AND YOUR CHECK OR MONEY ORDER TO STATE OF ALASKA:

DEPARTMENT USE ONLY

Department of Community and Economic Development

Alaska State Board of Public Accountancy

Division of Occupational Licensing

P.O. Box 110806

Juneau, Alaska 99811-0806

(907) 465-3811

E-mail: license@dced.state.ak.us

APPLICATION FOR REINSTATEMENT

Please refer to the last page of this application for information concerning reinstatements.

The amount due for

reinstatement depends upon how long the license has been lapsed. The current biennial fee is $220.00. Licenses lapsed

for less than three years must pay the biennial fee due for the entire time the license has been lapsed. Licenses lapsed for

more than three years pay no more than three times one year's portion of the fee that would have been required, providing

the board determines the failure to renew was excusable. Please note that licensing fees are subject to change and the

fee currently in place may not be the fee that was in place during the entire time the license was lapsed. Contact the division

for correct fee information.

FEES

Licensing

Fee

Name:

Period

Last

First

M.I.

Mailing Address:

City:

State:

ZIP Code:

Daytime Telephone No.:

License No.:

3 x Annual Fee

Date of Birth:

Social Security No.:

Total Due:

The Passage of Uniform CPA examination:

State(s)

Date(s)

List all Jurisdictions in which you hold or have held licenses to practice public accountancy.

Check here if NONE

State or Jurisdiction

License or Permit Number

First Issue Date

Expiration Date

Periods of Lapse?

EDUCATIONAL HISTORY:

High School Name

Location

Date Graduated

College or University

Dates in

Name

Address

Attendance

Credits

Degree

08-4144 (Rev. 9/00)

Form 08-4144 - Application For Reinstatement Form - Department Of Community And Economic Development Alaska State Board Of Public Accountancy Division Of Occupational Licensing

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