Application For Minnesota Cpa Certificate (License) By 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 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
(First)
(M.I.) (Last)
(Suffix)
Preferred “mail to”:
Home
Business
Former Name
(if applicable)
Employer Name
Social Security #
Birth Date
Gender:
Male
Female
Work Phone
(MM)
(DD)
(YYYY)
Home Phone
Work Fax
Home Address
Work Address
City
Work City
State
Zip
Work State
Work Zip
Date you passed the CPA Examination
(MM)
(DD)
(YYYY)
Section 2: 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 4) for
each person.
Name
Address
City
State
Zip
Application for MN CPA Certificate by MN Exam Candidate—Page 1 of 5
Rev 04/17

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