03-2018
North Carolina State Board of Certified Public Accountant Examiners
1101 Oberlin Road Suite 104 • PO Box 12827 • Raleigh NC 27605
Phone 919-733-1422 • Fax 919-733-4209 • Web www.nccpaboard.gov
EXPERIENCE AFFIDAVIT - PART-TIME
This form is a supplement to the Experience Affidavit. The direct supervisor must complete both forms and attach this
supplement to the Experience Affidavit. This form may be copied, but the direct supervisor must sign each page.
TO BE COMPLETED BY APPLICANT:
Full Name (First/Middle/Last/Suffix)
Mailing Address (Street or PO Box)
City, State, Zip Code
TO BE COMPLETED BY DIRECT SUPERVISOR:
The applicant was employed part-time in this office of my firm for the period beginning ,
(MM/DD/YYYY)
and ending (date of termination or today’s date) .
(MM/DD/YYYY)
Any weeks that are 30 hours or more are counted as full-time equivalent weeks [21 NCAC 08F .0401(b)].
Below is a listing of actual (not average) hours worked each week. These figures are correct to the best of my knowledge.
(MM/DD/YYYY)
Worked
(MM/DD/YYYY)
Worked
(MM/DD/YYYY)
Worked
Printed Name Signature Date
FOR BOARD USE
