Application For Retired Cpa/pa License Status - Oregon Board Of Accountancy (Page 3 of 3) in pdf

Application For Retired Cpa/pa License Status - Oregon Board Of Accountancy Page 3

DO NOT SEND THIS FORM WITHOUT ATTACHING THE APPLICATION

Credit/Debit Card Payment Authorization Form

Please return the application and this form to:

Oregon Board of Accountancy, 3218 Pringle Rd SE #110, Salem OR 97302

Questions? Please call 503-378-4181 or 503-378-2268

I authorize the Oregon Board of Accountancy to charge my Credit/Debit card listed below, and if necessary,

to initiate adjustments for any transactions credited or debited in error.

Applicant Name:

Application fee:

$50 - Required

Cardholder’s Information: Please PRINT and provide ALL information. Visa or MasterCard ONLY

Charge Amount:

Expiration Date:

Card Number:

Cardholder Name

(as it appears on the card)

Cardholder Billing Address:

Street, Apartment #

City

State, Zip Code

Daytime Phone Number

Cardholder’s Signature

Date

RETURN THIS FORM TO: Oregon Board of Accountancy, 3218 Pringle Rd SE #110, Salem OR 97302

Questions? Please call 503-378-4181 or 503-378-2268

DO NOT SEPARATE THIS SHEET FROM YOUR APPLICATION FORM

DO NOT EMAIL THE APPLICATION FORM OR PAYMENT SHEET

Retired Status Application

Oregon Board of Accountancy

March 2013

Application For Retired Cpa/pa License Status - Oregon Board Of Accountancy Page 3