Application For Minnesota Registered Accounting Practitioner (Rap) Registration - 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
REGISTERED ACCOUNTING PRACTITIONER (RAP) REGISTRATION
Application Fee: $50
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
Preferred “mail to”:
(First)
(M.I.) (Last)
(Suffix)
Home
Business
Former Name
(if applicable)
Employer Name
Social Security #
Gender:
Birth Date
Male
Female
Work Phone
(MM)
(DD)
(YYYY)
Work Fax
Home Phone
Home Address
Work Address
City
Work City
State
Zip
Work State
Work Zip
Section 2: Education and Examination
Degree type (check one):
Name of College/University
Associate Degree or Diploma in Accounting
Equivalent Education consisting of 60 semester hours
Date you passed the ACAT Examination
Score:
(MM)
(DD)
(YYYY)
Section 3: Affidavit
Have you ever held a CPA certificate and/or similar license in Minnesota or any other state?
Yes*
No
Have you ever been convicted of any crime or any other discreditable act?
Yes*
No
* If you answered “yes” to any of the above, provide a statement of explanation on a separate sheet of paper.
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
RAP Registration Application—Page 1 of 2
Rev 04/17

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