Cpa Sole Proprietor Firm Permit Renewal Application - Minnesota Board Of Accountancy - 2017 Page 6
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62017 NON-CPA OWNER OF FIRM STATEMENT
Each non-CPA owner must complete a copy of this form and submit the $45.00 fee.
1.
Personal Information
Name
Preferred “mail to”:
(First)
(M.I.) (Last)
(Suffix)
Home
Business
Former Name
(if applicable)
Firm Name
Social Security #
Date of Birth
Work Phone
(MM)
(DD)
(YYYY)
Home Phone
Work Fax
Home Address
Work Address
Work City
City
State
Zip
Work State
Work Zip
voting
2.
What percentage of
interest do you hold in the firm?
%
financial
3.
What percentage of
interest do you hold in the firm?
%
4.
List all the Minnesota professional licenses you hold and any disciplinary action taken
against those licenses in the last five years:
License #
Profession
Disciplinary Action (if any)
5.
Affidavit:
I certify that the above information is complete and accurate, that I actively participate
in the firm on a full-time basis, and that I agree to comply with the rules adopted by the
Minnesota Board of Accountancy.
Signature
Date
CPA Sole Proprietor Firm Permit Renewal Form—Page 5 of 5
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