Application For Minnesota Cpa Certificate (License) By Non-Minnesota Exam Candidate - Minnesota Board Of Accountancy Page 4

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Section 5: Personal References
List the names and current address of three responsible persons who:
a) are not related to you,
b) have known you for at least 2 years, and
c) can attest to your professional qualifications.
If possible, the list should include a CPA. Complete the top portion of a Personal Reference Form (page 6) for
each person.
Name
Address
City
State
Zip
Section 6: Affidavit
Have you ever had a CPA certificate, license or permit disciplined, denied, surrendered,
No
suspended or revoked?
Yes*
Have you ever been convicted of any crime or any other discreditable act?
Yes*
No
* If you answered “yes” to either question above, provide a statement of explanation on a separate sheet of paper.
I hereby apply for a Certificate of Certified Public Accountant in the State of Minnesota. I understand that
according to Minnesota Statutes and Rules, the act of filing this application shall constitute agreement upon my
part to observe the Board’s Statutes and Rules.
The statements given in this application are true and correct to the best of my knowledge and belief. I have not
suppressed any information which may have bearing upon this application and I know of no reason why my
application should not be approved.
Signature
Date
Application for MN CPA Certificate by NON-MN Exam Candidate—Page 3 of 7

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