Authorization For Interstate Exchange Of Exam And License Information - Oregon Board Of Accountancy Page 2

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AUTHORIZATION FOR INETERSTATE EXCHANGE OF EXAMINATION AND LICENSURE INFORMATION – Continued
Name
SECTION B: VERIFICATION OF EXAMINATION GRADES (To be completed by the Board of Accountancy Only)
Please provide only the information that resulted in the awarding of credit.
Section ID Number
Date Exam Taken
Grade
Expiration of Credit
AUD
BEC
FAR
REG
1. Has this applicant ever been denied admission to the exam? If yes, explain in Section D.
2. If the applicant has not completed the CPA examination, are there any restrictions
preventing the applicant from sitting in your jurisdiction?
3. Date applicant initially sat for the exam in your jurisdiction: Month
Year
SECTION C: LICENSURE INFORMATION (To be completed by the Board of Accountancy only)
1. The individual holds an original / reciprocal (circle correct response) CPA certificate #
dated
which is in good standing unless otherwise noted in Section D of this form
2. Is your jurisdiction considered two-tier?
3. The individual completed the AICPA ethics exam?
Score:
4. Indicate number of years’ experience required at the time the applicant was licensed:
5. The individual hold a license / permit that expires:
6. Has this individual had any disciplinary action with your Board?
7. Is there any pending disciplinary action against this individual?
SECTION D: EXCEPTIONS NOTED OR EXPLANATIONS OF INFORMATION PROVIDED
(Official seal and signature must be affixed to attached sheets if needed to respond to this inquiry)
THE INFORMATION PROVIDED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Affix Official Board 
Board/Agency
Seal Here 
Official Signature
Title
Date

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