Authorization For Interstate Exchange Of Exam And License Information - Oregon Board Of Accountancy

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AUTHORIZATION FOR INTERSTATE
Oregon Board of Accountancy
EXCHANGE OF EXAM AND
3218 Pringle Rd SE #110
LICENSE INFORMATION
Salem, OR 97302-6307
503-378-2264 FAX: 503-378-3575
Section A: AUTHORIZATION (To be completed by applicant)
This form is required for the application you are filing with the Oregon Board of Accountancy. Please complete
section I and immediately forward the form to the Board of Accountancy where your examination grades
and/or certificate and license were issued. That Board, in turn, will complete the remainder of the form and
return it to you or directly to the Oregon Board of Accountancy. You are advised to check with that Board
before forwarding this form to determine if there are additional requirements and/or fees before such
information will be released). Please print or type.
LEGAL NAME:
Address Line 1
Address Line 2
City
State
Zip Code
Province
Country
Primary Phone
Secondary Phone
Certificate Number
Date of Birth
I HEREBY REQUEST AND AUTHORIZE THE
Board of Accountancy to provide any and
all information requested on this form to the Oregon Board of Accountancy to complete an application filed
with that agency.
Signature
Date

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