Individual Cpa Certificate Renewal Application - Minnesota Board Of Accountancy - 2016 Page 2
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7M
B
a
Ph: 651-296-7938
innesota
oard of
ccountancy
CLEAR
CLEAR
Fax: 651-282-2644
85 East 7th Place, Suite 125
FORM
FORM
St. Paul, MN 55101-2143
2016 INDIVIDUAL CPA CERTIFICATE RENEWAL APPLICATION
ALL applicants regardless of certificate status must complete ALL questions on pages 1 and 2.
1.
Personal Information
(You must include both your home and work information even if you are self-employed.)
Military Status u Are you active duty or within 6 months of discharge from active duty?
No
Yes
Preferred “mail to”:
Home
Business
Name
Not currently employed
Retired
(First)
(M.I.) (Last)
(Suffix)
Certificate #
Employer Name
Work Phone
Home Phone
Email
Work Fax
Home Address
Work Address
City
Work City
State
Zip
Work State
Work Zip
2.
Select Status
(Mark choice in first column)
Renewal Fee
ü
Status for 2016
(Includes delinquency fee for renewal
postmarked after 12/31/2015)
Active
$150
Inactive
$75
Change from Active to Inactive
$75
Change from Inactive to Active
$150
Exempt
$50
Surrender Certificate
$0
3.
Do you work in public accounting as your primary occupation?
If yes, indicate business type below. If no, go to question 4.
Yes
No
CPA Corporation
CPA Limited Liability Company
CPA Limited Liability Partnership
CPA Partnership
CPA Sole Proprietorship
Governmental (list agency below)
Note: All firms, including Sole Proprietorships, engaged in providing attest or compilation services for a client having its
headquarters in Minnesota (as defined in MN Rule 1105.4150) or a firm with an office in Minnesota must obtain a
firm
permit.
CPA Certificate Renewal Form—Page 1 of 6
Rev 5/16
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