Section 3: Employment History/Experience Verification
List the employer(s)/CPA(s) who will verify your qualifying experience. Be sure that all addresses are current
and correct. For the duration and type of experience required, see
MN Rules 1105.2600
and 1105.2800. If you
are already licensed in another state, see also
MN Statute
326A.04.3.
Complete Part 1 of the
Experience Verification Form
(page 3) and have Part 2 completed by the
verifying CPA(s). The verifying CPA(s) should return that form directly to the Board office.
Employer Name
to
Employment Dates:
(MM/DD/YYYY)
(MM/DD/YYYY)
Address
Nature
of Work:
City
State
Zip
Name of
Verifying CPA
Employer Name
to
Employment Dates:
(MM/DD/YYYY)
(MM/DD/YYYY)
Address
Nature
of Work:
City
State
Zip
Name of
Verifying CPA
Employer Name
to
Employment Dates:
(MM/DD/YYYY)
(MM/DD/YYYY)
Address
Nature
of Work:
City
State
Zip
Name of
Verifying CPA
Employer Name
to
Employment Dates:
(MM/DD/YYYY)
(MM/DD/YYYY)
Address
Nature
of Work:
City
State
Zip
Name of
Verifying CPA
Section 4: Affidavit
Have you ever had a CPA certificate, license or permit disciplined, denied,
Yes*
No
surrendered, suspended or revoked?
Yes*
No
Have you ever been convicted of any crime or any other discreditable act?
* 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
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