Cpa Reciprocity Application For Cpa Certificate And Permit To Practice Public Accounting- Oregon Board Of Accountancy Page 5

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CREDIT/DEBIT CARD PAYMENT AUTHORIZATION FORM
~MUST ACCOMPANY RECIPROCITY 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.
Name
Date
Signature
$225— Reciprocity application fee (Required)
CARDHOLDER’S INFORMATION: (Please PRINT and provide ALL information.)
Charge Amount:
VISA OR MasterCard
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
CHECK,
If paying by
make check payable to:
CREDIT CARD,
If paying by
you may mail or fax to:
Oregon Board of Accountancy
Oregon Board of Accountancy
MAIL TO:
3218 Pringle Rd SE #110
Salem, OR 97302
Oregon Board of Accountancy
Unit 05
OR
PO Box 4395
Portland, OR 97208-4395
FAX: 503-378-3575
DO NOT SEPARATE THIS SHEET FROM YOUR APPLICATION FORM.
DO NOT EMAIL THE APPLICATION FORM OR PAYMENT SHEET.
Questions? Contact: (503) 378-2270 / julie.nadeau@oregon.gov or angel.m.legler@oregon.gov / (503)378-2264
2016 CPA RECIPROCITY APPLICATION

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