North Carolina State Board of Certified Public Accountant Examiners
1101 Oberlin Road Suite 104 PO Box 12827 • Raleigh NC 27605
Phone 919-733-1423 • Fax 919-733-4209 • Web nccpaboard.gov
Full Name (First/Middle/Last/Suffix)
NC CPA Certificate Number
Employer Name
Mailing Address (Street or PO Box and City, State, Zip Code)
This is my Home Address Business Address Is this a change of mailing address? Y N
Daytime Telephone Number Email Address
If you were previously approved for an extension, attach a copy of the form returned to you by the
All questions must be answered for this request to be processed.
A. I request an extension until (MM/DD/YYYY), no later than June 30, to complete my
annual CPE requirement.
B. I completed hours (including carry forward), by December 31, toward the annual CPE
C. I need hours to complete the annual CPE requirement.
D. Reason for extension Attach a separate sheet that explains why you are requesting an extension.
Include all pertinent information so that the Board may make an informed decision.
If you were enrolled in a CPE course, but were unable to attend because of the reason stated, you
must attach a copy of your registration form.
Attach a copy of any documentation (e.g., doctor's statement, accident report, etc.) that supports
your extension request.
If self-study courses are not an option for you, please explain in writing.
I have read the CPE rules of the Board as found in 21 NCAC 08G .0400 and do certify under the penalties
provided by law to the truth and accuracy of the information submitted above.
Signature Date
Request has been considered by the Board and was:
Approved to: Denied
Meeting Date: Authorized Signature: