Cpe Audit Form For The Three-Year Reporting Period July 1, 2013-June 30, 2016 - Minnesota Board Of Accountancy Page 3

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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
CPE AUDIT FORM
FOR THE THREE-YEAR REPORTING PERIOD JULY 1, 2013-JUNE 30, 2016
Name
Certificate #
(First)
(M.I.) (Last)
(Suffix)
Self-Study Course
Course Hours from
Course Hours from
Hours from a
Non-Approved
Fiscal Year ended
Approved Sponsors
NASBA Quality
Sponsors
Total
June 30
(Excluding
Assurance Service
(Excluding
self-study)
Sponsor
self-study)
2014
2015
2016
Deduct any carryback hours earned between 7/1/2013 and 6/30/2016 that were
used to satisfy CPE requirements for years ended June 30, 2013 and prior.
Total hours earned after June 30, 2016 needed to satisfy minimum requirement
(carryback hours).
Include certificates of completion and CPE Non-Compliance
Fees (see below **) if you have not already submitted these items to Board.
Total for 3 years
(Must equal at least 120 hours)
Important:
If you have already carried back credits to Reporting Years 2014, 2015 or 2016 and paid the CPE
**
noncompliance fees, please list those courses in the year to which you carried them back (not the year you took them)
and do not enter anything in the carryback fields on this form.
If, however, in reviewing your CPE totals, you find you must use carryback hours to meet the required CPE
minimums, enter the hours in the carryback fields and read the following: Failure to report CPE, failure to obtain
CPE required by this part, reporting of an amount less than that required, or fraudulently reporting CPE is a basis for
disciplinary action under
Minnesota Statutes, section
326A.08. A licensee not in compliance with this part on June 30 of
each year will be assessed a late processing fee of $50 for the first month, or partial month, of noncompliance and $25
per month, or partial month, of noncompliance thereafter until the date the licensee is in compliance with this part and
provides documentation of compliance in writing to the Board.
I certify that all of the information I provided on these forms is accurate, and I understand that any
misrepresentation could result in disciplinary action.
Signature
Date
Daytime Phone
CPE Audit FORM—Page 1 of 6
Rev 05/17

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