Application For Temporary Military Certificate (Mn Cpa) - Minnesota Board Of Accountancy Page 4
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4M
B
a
Ph: 651-296-7938
innesota
oard of
ccountancy
CLEAR
CLEAR
Fax: 651-282-2644
85 East 7th Place, Suite 125
FORM
FORM
boa.state.mn.us
St. Paul, MN 55101-2143
AUTHORIZATION FOR INTERSTATE EXCHANGE OF
EXAMINATION AND CERTIFICATION INFORMATION
Applicant:
Please sign and date this form and send it to the state that has your exam scores or in which you have been licensed/certified.
Section A: Applicant Contact Information and Authorization
Last 4
Name
Former Name
of SS #
xx-xxx-
(First)
(M.I.) (Last)
(Suffix)
(if applicable)
Address
City
State
Zip
I am applying to the Minnesota Board of Accountancy for a Minnesota CPA license. I authorize the Verifying Board to provide any and
all pertinent information requested.
Signature
Date
Verifying Board:
Please complete
Sections B and C
and return to the Minnesota Board at the address above.
Section B: Examination Scores
(Please list all grades, including failing grades, recorded for the applicant)
Auditing and
Business Environment
Financial Auditing and
Exam Date
AICPA ID#
Regulation (REG)
Attestation (AUD)
and Concepts (BEC)
Reporting (FAR)
Was the applicant ever denied admission to the exam?
No
Yes If Yes, explain
Subjects for which candidate has been granted credit:
None
AUD
BEC
FAR
REG
Section C: Certificate Status
CPA Certificate held by applicant is
Original
Reciprocal. Certificate #
Dated
Has the applicant successfully completed an AICPA Ethics Examination?
Yes
No
Does the applicant hold a CPA license/permit to practice public accounting from your Board and is it in good standing?
Yes
No
Has the applicant met all of the qualifications for licensure from your Board?
Yes
No
Please indicate the requirements in your state that must be met for issuance or reinstatement of a license (select all that apply):
License/Permit not required
Pay appropriate fees or post bond
Complete acceptable accounting/auditing experience
Complete CPE requirements
Other (please specify)
Has your Board ever suspended or revoked the applicant’s certificate, permit or license to practice?
Yes
No
Has the applicant ever been censured or reprimanded by your Board?
Yes
No
The information provided herein is correct to the best of our knowledge.
Board
Name of State Board:
Seal
Signature:
Print Name:
Title:
Date:
Application for Temporary Military Certificate (MN CPA)—Page 3 of 3
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