General Permit To Practice Form - 2000 Page 2
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1
2
3ALASKA 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. Before your application can be considered for approval,
the information requested below must be officially verified by the accountancy board where your license status was
established. Please complete the information requested and FORWARD IT TO THE BOARD WHERE STATUS WAS
ESTABLISHED and they, in turn, will complete the remainder of this form and return it to this agency. 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 Firm:
Mailing Address:
City:
State:
ZIP Code:
Daytime Telephone Number:
Social Security Number:
I hereby request and authorize the
to provide any and all
pertinent information requested in this form to the Alaska Board of Public Accountancy to complete and application filed with
that agency.
Signature
Date Signed
SECTION B – LICENSE/PERMIT TO PRACTICE PUBLIC ACCOUNTING
The firm 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 No.:
Issue Date:
Expiration Date:
o
o
o
o
o
License Status:
Current
Lapsed
Pending Litigation
Suspended
Revoked
o
o
Have licensee, partners, and/or shareholders met the continuing education requirement?
Yes
No
Number of hours per year
SECTION C – ADDITIONAL INFORMATION
SECTION D – EXCEPTIONS OR EXPLANATIONS OF INFORMATION PROVIDED
This information provided herein is correct to the best of our knowledge.
Board
OFFICIAL BOARD SEAL
Board Official Signature
Please return this form to:
Department of Community and
Economic Development
Title
Alaska State Board of Public Accountancy
P.O. Box 110806
Juneau, Alaska 99811-0806
Date
(907) 465-3811
08-2443a (Rev. 9/00)
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