State Form 49209 - Accountancy Application - Part I

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ACCOUNTANCY APPLICATION

INDIANA BOARD OF ACCOUNTANCY

PART I

PROFESSIONAL LICENSING AGENCY

402 West Washington Street, Room W072

State Form 49209 (R3 / 3-09)

Indianapolis, Indiana 46204

Telephone: (317) 234-3040

Approved by State Board of Accounts, 2009

E-mail: pla11@pla.IN.gov

INSTRUCTIONS:

Please type or print legibly.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1; disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY

Application fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

License obtained by

DO NOT WRITE ABOVE THIS LINE

GENERAL INFORMATION

Type of application (please check one)

CPA certificate

Reciprocity certificate

Transfer of grades

Reciprocity certificate by substantial equivalency

Name of applicant (last, first, middle)

Social Security number *

Previous names used

Address (number and street, city, state, and ZIP code)

Date of birth (month,day, year)

Home telephone number

Business telephone number

E-mail address

(

)

(

)

Have you ever been convicted of:

Yes

A. An act which would constitute a ground for disciplinary sanction under IC 25-1-11-5

Yes

B. A felony that has a direct bearing on your ability to practice competently

If yes, please attach supporting documentation relevant to the conviction.

Date you passed the CPA examination (month, day, year)

State in which you passed the examination

Do you have an advanced degree in accounting or

business administration?

Yes

If yes, name of institution conferring degree

Date degree conferred (month, day, year)

Do you hold a license in good standing as a certified public

accountant from a state other than Indiana?

Yes

If yes, please complete the below table.

STATE WHERE ISSUED

LICENSE NUMBER

DATE ISSUED (month, day, year)

APPLICANT AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete, and correct.

Signature of applicant

Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization, or institution to release to the Indiana Professional

Licensing Agency, or the Indiana Board of Accountancy, any files, documents, records, or other information pertaining to the undersigned requested by

the Agency, or the Board, or any of their authorized representatives, in connection with processing my application for licensure.

I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to

such inspection or furnishing of any such information.

I further authorize the Indiana Professional Licensing Agency or the Indiana Board of Accountancy to disclose to the aforementioned persons, firms, officers,

corporations, associations, organizations, and institutions any information, which is material to my application, and I hereby specifically release the Agency,

and the Board from any and all liability in connection with such disclosures.

A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.

Signature of applicant

Date signed (month, day, year)

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