certified public accountant procedure sheet for licensure - Alaska ...

MAIL COMPLETED APPLICATION AND FEES TO: CPA
State of Alaska
Department of Commerce, Community and Economic Development
Division of Corporations, Business and Professional Licensing
BOARD OF PUBLIC ACCOUNTANCY
550 West 7 th For Division Use Only
Avenue, Suite 1500
Anchorage, AK 99501
Phone: (907) 269-4712 Fax: (907) 269-8156
E-mail: license@alaska.gov
Website: www.commerce.alaska.gov/occ/
APPLICATION FOR CERTIFIED PUBLIC ACCOUNTANT LICENSE
Nonrefundable Application Fee: $ 50.00 Make checks payable to: STATE OF ALASKA
Certification Fee: $ 220.00
Wall Certificate (Optional): $ 20.00
I HEREBY APPLY for Certification by EXAMINATION Certification by RECIPROCITY
(Must have at least four years post exam
experience within last ten years)
1. Name:
Last First M.I. Maiden or Other Names
Salutation: Mr. Mrs. Ms. S.S.N:
2. CONTACT INFORMATION
Mailing Address:
Daytime Telephone Number:
(Required by AS 08.01.060)
City State ZIP Code
Area Code
Email Address: ______________________________________________________________________________
3. Date of Birth:
Please send correspondence via Email US Mail
Mo. Day Year
4. EXAM INFORMATION
Passage of Uniform CPA examination:
State(s) Registered: Date Final Section Passed:
Date Ethics Exam Passed? Administered by:
(AICPA Professional Ethics Comprehensive Course required for CPA Licensure by Examination)
5. LICENSURE INFORMATION
a. List all Jurisdictions in which you hold or have held certificates/licenses to practice public accountancy.
Check here if NONE
State or Jurisdiction License or Permit Number First Issue Date Expiration Date Periods of Lapse?
08-4092 (Rev. 08/22/12) (1)