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Form 08-4060b - Biennial Certified Public Accountant/ Public Accountant License Renewal Page 2

PROFESSIONAL FITNESS

Since the date of your last application for an Alaska CPA or PA license:

YES

Has your professional license been denied revoked, suspended, surrendered, stipulated, on

probation, or been subject to any other restriction or disciplinary action in any jurisdiction? ............

Have you had the right to practice before any state or federal agency denied, suspended, or

revoked? ............................................................................................................................................

Have you been found guilty of dishonesty, fraud, gross negligence in the practice of public

accounting, or other acts discreditable to the accounting profession? ..............................................

Have you had any felony convictions? ..............................................................................................

If you answered "Yes" to any of the above questions, please explain dates and circumstances on a separate piece of paper, and send any

supporting documents that are applicable (court records, etc.). Yes answers may not automatically result in denial of renewal.

CONTINUING EDUCATION

Please complete the attached continuing education report form and return with your renewal. Persons with license numbers AA 1769

and above are not required to complete the continuing education form, however, continuing education will be a requirement for

subsequent renewals.

QUALITY REVIEW

Please complete the attached Quality Review Reporting form and return with your renewal. All licensees must complete the Quality

Review Reporting form.

WARNING: The Board of Public Accountancy may deny, suspend, or revoke the license of a person who has obtained or attempted to

obtain a license to practice public accounting by fraud or deceit. The person may also be subject to criminal charges for perjury or unsworn

falsification. (AS 11.56.210 and AS 11.56.230)

I certify that the information in this application is true and correct.

SIGN HERE

Applicant's Signature

Date:

SUBSCRIBED AND SWORN TO before me this

day of

Notary Public for the State of

My Commission expires

NOTIFICATION OF PROPOSED REGULATIONS CHANGES

If you would like to receive notice of all proposed Public Accountancy regulation changes, please send a written request

adding your name to the Public Accountancy Interested Parties List to:

REGULATIONS SPECIALIST

Department of Community and Economic Development

Division of Occupational Licensing

P.O. Box 110806, Juneau, Alaska 99811-0806

08-4060 (Rev. 10/99)

(2)

Form 08-4060b - Biennial Certified Public Accountant/ Public Accountant License Renewal Page 2