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
EXPERIENCE VERIFICATION FORM
(For CPA Application)
Applicant:
Please complete
Part 1
for each verifying CPA you listed in “Employment History” on your application and send it to them.
Part 1 – To be completed by the applicant
Applicant
Employment Dates:
to
Name
(First)
(M.I.) (Last)
(Suffix)
(MM/DD/YYYY)
(MM/DD/YYYY)
Company Name
Full Time
Part Time*
Temporary*
Company Address
*Number of hours of experience obtained, if employment
was part time or temporary:
City
State
Zip
Describe, in detail, the nature of the work you performed including such factors as the complexity and diversity
of the work performed:
Verifying CPA:
Please complete
Part 2
of this form and return the form to the Board of Accountancy at the address listed above.
Do not return to the applicant.
NOTE:
You must hold an Active or an Inactive license (from any jurisdiction) in good standing and
have sufficient knowledge of the information provided above in order to serve as the verifying CPA.
Part 2 – To be completed by the CPA verifying the applicant’s experience.
The above-named individual is applying for a CPA License. Please complete the following questions:
Yes
No*
Do you believe the above information is accurate?
Do you know of any reason the applicant should not be considered for a CPA license?
Yes*
No
Do you recommend the applicant for a CPA license?
Yes
No*
*If you checked a box with an asterisk (*) provide an explanation below or use the back of this form.
I have read the above and believe it to be true, correct and complete to the best of my knowledge.
I understand that I may be asked to substantiate the basis for my verification.
Status:
Active or
Printed Name
CPA License #
Inactive
Signature
State Where Licensed
Date
Application for MN CPA Certificate by NON-MN Exam Candidate—Page 5 of 7
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