Cpe Audit Form For The Three-Year Reporting Period July 1, 2013-June 30, 2016 - Minnesota Board Of Accountancy Page 4

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Name
Please give a breakdown of your CPE hours for each fiscal year in the following tables.
DO NOT USE YOUR OWN FORM.
FISCAL YEAR 2014 (Hours completed July 1, 2013 to June 30, 2014)
Self-Study Course
Course Hours from
Hours from a NASBA
Course Hours from
Non-Approved
Quality Assurance
Approved Sponsors
Sponsors
Type of Credits
Service Sponsor
Total
(Not including self-study)
(Not including self-study)
General
Ethics
Personal Development
Teaching
N/A
Writing
Total for fiscal year ending June 30, 2014
FISCAL YEAR 2015 (Hours completed July 1, 2014 to June 30, 2015)
Self-Study Course
Course Hours from
Hours from a NASBA
Course Hours from
Non-Approved
Quality Assurance
Approved Sponsors
Sponsors
Type of Credits
Service Sponsor
Total
(Not including self-study)
(Not including self-study)
General
Ethics
Personal Development
Teaching
N/A
Writing
Total for fiscal year ending June 30, 2015
FISCAL YEAR 2016 (Hours completed July 1, 2015 to June 30, 2016)
Self-Study Course
Course Hours from
Hours from a
Course Hours from
Non-Approved
NASBA-Approved
Approved Sponsors
Sponsors
Type of Credits
Self-Study Sponsor
Total
(Not including self-study)
(Not including self-study)
General
Ethics
Personal Development
Teaching
N/A
Writing
Total for fiscal year ending June 30, 2016
**Total hours earned after June 30, 2016 needed to satisfy minimum requirement (carryback
hours).
Include certificates of completion and CPE Non-Compliance Fees if not already submitted.
Total for Three Years
** See “IMPORTANT” note on
page 1
to
determine if you need to list any carryback hours.
(Must meet minimum requirement of 120 hours)
CPE Audit FORM—Page 2 of 6

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