Application For Minnesota Registered Accounting Practitioner (Rap) Registration - 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
EXPERIENCE VERIFICATION FORM
(For RAP Application)
Applicant:
Please complete
Part 1
of the form and send a copy to the RAP(s) or CPA(s) verifying your experience.
Part 1 – To be completed by the applicant
Applicant
Employment Dates:
to
Name
(First)
(M.I.) (Last)
(Suffix)
(MM/DD/YYYY)
(MM/DD/YYYY)
Company Name
Full Time
Part Time*
Temporary*
Company Address
*Number of hours of experience obtained, if employment
was part time or temporary:
City
State
Zip
Describe, in detail, the nature of the work you performed including such factors as the complexity and diversity
of the work performed:
Verifying RAP or CPA:
Please complete
Part 2
and return the form to the Board of Accountancy at the address listed above. Do not
return to the applicant.
NOTE:
To verify the applicant’s experience, you must have sufficient knowledge of the information provided
above and your own license must be in good standing (verifying CPAs must hold an Active or an Inactive license—any jurisdiction).
Part 2 – To be completed by the RAP or CPA verifying the applicant’s experience.
The above-named individual is applying for a RAP Registration. Please complete the following questions:
Do you believe the above information is accurate?
Yes
No*
Do you know of any reason the applicant should not be considered for registration as a
RAP?
Yes*
No
Do you recommend the applicant for registration as a RAP?
Yes
No*
*If you checked a box with an asterisk (*) provide an explanation below or use the back of this form.
I have read the above and believe it to be true, correct and complete to the best of my
knowledge. I understand that I may be asked to substantiate the basis for my verification.
CPA Status (if applic):
Printed Name
RAP Reg. or CPA Certif. #
Active
Inactive
Signature
State of Certification
Date
RAP Registration Application—Page 2 of 2

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