North Carolina State Board of CPA Examiners
1101 Oberlin Road, Suite 104 • PO Box 12827 • Raleigh, NC 27605
Phone (919) 733-4222 • Fax (919) 733-4209 • Web www.nccpaboard.gov
Notice of Address Change
Certificate Holder
Certificate No.
Exam Candidate
Last four (4) digits of Social Security No.
Firm
Name of Supervising CPA:
NAME
Full Name (First/Middle/Last/Suffix)
MAILING ADDRESS
Business Name
Address (Street or PO Box and City, State, Zip Code)
Telephone Number Email Address
HOME ADDRESS
Address (Street or PO Box and City, State, Zip Code)
Telephone Number Email Address
BUSINESS ADDRESS
Business Name
Address (Street or PO Box and City, State, Zip Code)
Main Telephone Number Direct Telephone Number
Fax Number Email Address
NOTE: The address to which the Board sends mail (“mailing address”) is also the address that will be displayed on the
Board’s website. If you do not wish for your home address and telephone number to be displayed on the Board’s
website, you must use your business address as your mailing address.
U
nder penalties of perjury, I affirm that the above information is true, accurate, and complete.
Signature Date
Mail completed form to: Fax completed form to: (919) 733-4209
State Board of CPA Examiners
PO Box 12827 Email completed form to:
Raleigh, NC 27605-2827 vanessiaw@nccpaboard.gov
