State Form 45408 - Request For Issuance Of An Indiana Cpa Certificate
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1
2Indiana Board of Accountancy
REQUEST FOR ISSUANCE OF
302 West Washington Street, Room E034
Indianapolis, IN 46204-2700
AN INDIANA CPA CERTIFICATE
State Form 45408 (R2 / 5-94)
NOTE: Work experience that began under IC 25-2-1 will be recognized after December 31, 1993, provided that you are currently employed
by that employer. If you began new employment on or after January 1, 1994, your experience will be reviewed under IC 25-2.1.
Date (month, day, year)
Telephone number (home)
Telephone number (work)
Name of requestor (last, first, middle)
Address (number and street, city, state, ZIP code)
CONFIRMATION OF DEGREE
Date degree conferred.
Have you been conferred a Master's Degree?
Yes
No
Name and address of institution conferring degree.
PLEASE FURNISH THIS OFFICE WITH AN OFFICIAL TRANSCRIPT OF ALL CONFERRED DEGREES IF NOT PREVIOUSLY FILED.
CRIMINAL RECORD INFORMATION
Have you ever been convicted by a court of offenses other than minor traffic violations? (if "Yes", please attach details)
Yes
No
CPA EXAMINATION INFORMATION
Name of the state in which you passed the examination.
Date you passed the CPA examination (month, day, year)
ACCOUNTING EXPERIENCE CONFIRMATION
Accounting firm permit number
Name of present employer
Date employed
From
To
Address (number and street, city, state, ZIP code)
Telephone number
Name of supervising licensee
License number
Brief job description
Accounting firm permit number
Name of past employer
Date employed
From
To
Address (number and street, city, state, ZIP code)
Telephone number
Name of supervising licensee
License number
Brief job description
Continued on back
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