Cpa Initial License Application For Cpa Certificate And Permit To Practice Public Accounting - Oregon Board Of Accountancy Page 6

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CREDIT/DEBIT CARD PAYMENT AUTHORIZATION FORM
~MUST ACCOMPANY FIRM REGISTRATION 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
$225.00 —
Initial CPA Application Fee (Required)
CARDHOLDER’S INFORMATION: (Please PRINT and provide ALL information.)
$225.00
VISA OR MasterCard
Expiration Date:
Charge Amount:
Card Number:
Cardholder Name (as it appears on the card):
Cardholder Billing Address:
Street/ Apartment #
City
State
Zip Code
Daytime Phone Number
Date
Cardholder’s
Signature—REQUIRED
If paying by Check, make check payable to:
If paying by Credit Card, you may mail or fax to:
Oregon Board of Accountancy
Oregon Board of Accountancy
3218 Pringle Rd SE #110
MAIL TO:
Salem, OR 97302
Oregon Board of Accountancy
OR
Unit 05
PO Box 4395
FAX: 503-378-3575
Portland, OR 97208-4395
IF PAYING BY CREDIT CARD: SEND THIS FORM WITH YOUR APPLICATION
DO NOT EMAIL CREDIT CARD INFORMATION
Questions? Contact: (503) 378-2270 /
julie.nadeau@oregon.gov
or (503)378-2264 /
angel.m.legler@oregon.gov
2016 INITIAL CPA APPLICATION PG 3

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