Cpa Reciprocity Application For Cpa Certificate And Permit To Practice Public Accounting- Oregon Board Of Accountancy Page 2

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Oregon Board Of Accountancy
CPA RECIPROCITY APPLICATION
Attach Photo
FOR CPA CERTIFICATE AND PERMIT TO PRACTICE PUBLIC ACCOUNTING
Here
APPLICATION FEE: $225.00
1
GENERAL INFORMATION
PRINT
FIRST
MIDDLE
LAST
Full Name:
Previous Name(s):
I would like my name lettered on my certificate as:
IF YOU USE A PO BOX OR OTHER MAIL SERVICE YOU MUST ALSO PROVIDE A PHYSICAL ADDRESS. PLEASE CHECK BOX TO INDICATE OFFICIAL MAILING ADDRESS
Physical Home Address:
City:
State:
Zip Code:
PO Box:
Phone #:
E-mail:
IF SELF-EMPLOYED, INCLUDE NAME OF BUSINESS, TYPE OF BUSINESS AND ADDRESS. INDICATE IF UNEMPLOYED.
*Employer Name:
Employment Physical Address:
City:
State:
Zip Code:
PO Box:
Phone #:
E-mail:
Uniform CPA Exam passed in ___________________________________ on ______________________________
STATE
EXAM DATE (MONTH / YEAR)
List any state(s) in which you are currently licensed to practice public accounting:
STATE
LICENSE #
DATE ISSUED
STATE
LICENSE #
DATE ISSUED
STATE
LICENSE #
DATE ISSUED
STATE
LICENSE #
DATE ISSUED
List any state(s) in which you have previously held a valid permit to practice public accounting:
STATE
LICENSE #
DATE ISSUED
STATE
LICENSE #
DATE ISSUED
BOA USE ONLY
C
D
P
SEQ#
B
#
LERK
ATE
ROCESSED
ATCH
Questions? Contact: (503) 378-2270 / julie.nadeau@oregon.gov or angel.m.legler@oregon.gov / (503)378-2264
2016 OCTOBER CPA RECIPROCITY APPLICATION PG 1

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