Application For Minnesota Sole Proprietor Firm Permit - Minnesota Board Of Accountancy Page 6
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6MINNESOTA NON-CPA OWNER OF FIRM STATEMENT
Complete if you are a
non-CPA owner who is a resident of Minnesota
(regardless of the firm’s location[s])
and submit
$45.00
fee.
1.
Personal Information
I am a resident of Minnesota.
Firm Name
Name
Address
(First)
(M.I.) (Last)
(Suffix)
Former Name
City
(if used previously)
Work Phone
State
Zip
2.
What percentage of
voting
interest do you hold in the firm?
%
3.
What percentage of
financial
interest do you hold in the firm?
%
4.
List all the Minnesota professional licenses you hold and any disciplinary action taken
against those licenses in the last five years:
License #
Profession
Disciplinary Action (if any)
5.
Affidavit:
I certify that the above information is complete and accurate, that I actively participate in the firm on
a full-time basis, and that I agree to comply with the rules adopted by the Minnesota Board of Accoun-
tancy.
Signature
Date
Application for Sole Proprietor Firm Permit——Page 5 of 5
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