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

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2
ALL APPLICANTS MUST ANSWER THE FOLLOWING QUESTIONS
YES
NO
A) Are you now or have you ever applied for or been issued a certificate or license as a CPA or PA in this or
any other state?
B) Have you ever been arrested, charged with or convicted of a felony?
C) Have you been arrested, charged with or convicted of a non-felony crime in which the essential element
is fraud, dishonesty or misrepresentation?
D) Have you been a party to any legal proceedings including any non-disclosure agreements or tolling
(deadline extension/suspension) agreements?
E) Have you had any professional license suspended, revoked or restricted or been the subject of any
regulator’s investigation or action?
F) Are you currently under investigation or have action pending by another regulatory agency?
G) Do you have any pending expulsions or have you been expelled from a professional society?
If you answered yes to any of the questions above, please complete the
Disposition Form
3
CERTIFICATION
I certify to the truth and accuracy of all statements, answers and representations made in the foregoing application,
including all supplementary statements. I understand that any certificate issued to me must be surrendered upon
demand by the Oregon Board of Accountancy upon my failure to pay the fees prescribed by law, or upon revocation
by the Board of my certificate, or for other causes as prescribed by law. I understand and agree that the Board may
investigate the statements made on this application, and may conduct other investigations, including a criminal records
check.
Signature
Date
Affix recent photo of
applicant taken within the
past 6 months
NOTARY CERTIFICATE
State of
My Commission Expires
County of
Signed or attested before me on
20
by
Notary Public Signature
ANY FALSE STATEMENT OR MISREPRESENTATION ON THIS APPLICATION IS CAUSE FOR DENIAL
OF THE APPLICATION OR REVOCATION OF ANY LICENSE ISSUED UNDER THIS APPLICATION
or (503)378-2264 / angel.m.legler@oregon.gov
Questions? Contact: (503) 378-2270 /
julie.nadeau@oregon.gov
2016 INITIAL CPA APPLICATION PG

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