Application For Reinstatement Of A Revoked Certificate - Minnesota Board Of Accountancy - 2017

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CLEAR
CLEAR
M
B
a
Ph: 651-296-7938
innesota
oard of
ccountancy
FORM
FORM
Fax: 651-282-2644
85 East 7th Place, Suite 125
boa.state.mn.us
St. Paul, MN 55101-2143
APPLICATION FOR REINSTATEMENT OF A REVOKED CERTIFICATE
Military Only u If you are active duty or within 6 months of discharge from active duty, check box:
Name
Certificate #
(First)
(M.I.) (Last)
(Suffix)
Address
Home Phone
City
Work Phone
State
Zip
Provide your employment history for the period since revocation, listing the most recent employer
first. Include a description of the type of services you perform(ed). Use additional sheets as needed.
Employer Name & Address
Dates Employed
Types of Services Performed
Have you ever been suspended, expelled, revoked or otherwise disciplined in any manner
Yes
No
by any organization related to the practice of public accounting?
Have you ever been convicted of any crime, misdemeanor or any other discreditable act?
Yes
No
What was your certificate status prior to revocation?
Active
Inactive
Affidavit: I acknowledge that since the date of revocation of my certificate, I have not applied for or been
issued a certificate by the Board. Further, I acknowledge that since revocation of my certificate, I have not
engaged in activities requiring an active certificate. I certify that the information supplied on this application for
reinstatement is accurate and that any misrepresentation may be cause for disciplinary action. In accordance
with Minn. Stat. §326A.09 (2016), the undersigned requests reinstatement of the revoked certificate.
Signature
Date
Data Practices Act Warning
The data you furnish on this form will be used by the Board to process your application for licensure. You are not
legally required to provide this data; however, if you fail to do so, the Board may be unable to issue your license.
Until licensure is granted all application data, except name and designated address, are private data pursuant to
Minnesota Statutes section 13.41, subdivision 2 (2016). All data, except social security number and email address
become public record when licensure is granted pursuant to Minnesota Statutes section 13.41, subdivision 5 (2016).
Application for Reinstatement FORM—Page 1 of 1
Rev 06/17

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