Application For Retired Cpa/pa License Status - Oregon Board Of Accountancy
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3Oregon Board of Accountancy
APPLICATION FOR RETIRED CPA/PA LICENSE STATUS
* Required
Application Fee: $50.00
1. *Name
Last
First
Middle
Other last names known by:
2. Oregon CPA/PA License Number _______________
3. *Physical Home Address
*City
*State
*Zip
______
*Mailing Address:
____________________________________
(Mailing Address if different than Home Address)
*City____________*State
*Zip
Phone No.
*E-Mail Address:
____________
4. Check all that apply:
Employed
Business Name – Address – Phone Number
Unemployed
Retired
Contractor
Volunteer (
)
using accounting or auditing skills
Organization – Address – Phone Number
5. I qualify for Retired Status because:
A. I have held an active CPA or PA license in Oregon total combined period of at least 20 years; or
B. I am at least 65 years of age
*Date of Birth (00/00/0000)
BOA USE ONLY:
Clerk: __________________
Date Processed: _____________
Seq #:
Batch #: _________________
January 2016
Retired Status Application
Oregon Board of Accountancy
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