Application For Minnesota Cpa Certificate (License) By Non-Minnesota Exam Candidate - Minnesota Board Of Accountancy Page 2

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M
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
APPLICATION FOR MINNESOTA CPA CERTIFICATE (LICENSE)
BY NON-MINNESOTA EXAM CANDIDATE
Application Fee: $150
Complete
ALL
sections of the application form.
Section 1: General Information
Are you or your spouse an active duty military member? Or have you left service
in the last two years with an honorable or general discharge?
No
Yes
Contact Details:
Name
Preferred “mail to”:
(First)
(M.I.) (Last)
(Suffix)
Home
Business
Former Name
(if applicable)
Employer Name
Social Security #
Gender:
Birth Date
Male
Female
Work Phone
(MM)
(DD)
(YYYY)
Work Fax
Home Phone
Home Address
Work Address
City
Work City
State
Zip
Work State
Work Zip
Is your principal place of business in the State of Minnesota?
Yes
No*
*If no, explain why you need a Minnesota Certificate below:
Have you previously applied to the
Minnesota Board of Accountancy?
No
Yes (specify when:
)
Date you passed the CPA Examination
As a candidate for which state?
(MM)
(DD)
(YYYY)
Section 2: Education
College/University Attended
City, State
Degree Received
Date Graduated
Application for MN CPA Certificate by NON-MN Exam Candidate—Page 1 of 7
Rev 04/17

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