Application For Admission To The Roster Of Accountants Authorized To Conduct Municipal Audits - Oregon Board Of Accountancy Page 5

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OREGON BOARD OF ACCOUNTANCY
APPLICATION FOR ADMISSION TO THE ROSTER OF ACCOUNTANTS
AUTHORIZED TO CONDUCT MUNICIPAL AUDITS
Credit/Debit Card Payment Authorization Form
DO NOT SEND THIS FORM WITHOUT ATTACHING THE APPLICATION
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.
Licensee Name:
License #:
__________________________________________
___________________________
Signature
Date
___________________________________________________________________________
Pro-rated Permit Invoice issued upon approval of application
Municipal Auditor Permit Fee:
Application Fee:
$150 - Non-Refundable
Cardholder’s Information: Please PRINT and provide ALL information.
Charge Amount:
$
Visa OR MasterCard Exp Date:
Card Number:
Cardholder Name (as it appears on the card):
Cardholder Billing Address:
Street, Apartment/Suite #
City
State, Zip Code
Daytime Phone Number
Cardholder’s Signature
Date
RETURN THIS FORM TO:
If paying by CHECK:
If paying by CREDIT CARD:
Mail to:
Mail to:
Oregon Board of Accountancy
Oregon Board of Accountancy
Unit 05
3218 Pringle Rd SE #110
PO Box 4395
Salem, OR 97302
Portland, OR 97208
Or FAX to 503-378-3575
DO NOT EMAIL THE APPLICATION FORM OR PAYMENT SHEET

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