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11/2017
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
NOTIFICATION OF INTENT TO PRACTICE IN NORTH CAROLINA: OUT-OF-STATE CPA FIRM
This application is for use by a CPA firm from another US jurisdiction whose principal place of business is outside of NC and
does not have an office in NC but intends to offer or render professional services to clients in this State as described in
NCGS 93-10(c)(3).
CPA Firm Name:
Mailing Address:
City, State & ZIP:
Phone Number: Fax Number:
Website Address:
Supervising CPA:
Supervising CPA’s Email Address:
Last Peer Review Acceptance Date Administering Entity
Our Firm provides or intends to provide the following services (Check all applicable):
Any financial statement audit or other engagement performed in accordance with the Statements on Auditing
Standards (SAS); Generally Accepted Government Audit Standards (GAGAS), or International Standards on
Au
diting (ISA);
A
ny engagement performed in accordance with the Statements on Standards for Attestation Engagements
(SSAE); or
Any engagement performed in accordance with the Public Company Accounting Oversight Board (PCAOB)
auditing standards.
AFFIRMATION OF FIRM REPRESENTATIVE
I affirm that each CPA who will offer to perform or will perform services in North Carolina holds a valid and unrevoked certificate
as a certified public accountant or its equivalent, issued by another state, a territory of the United States, or the District of
Columbia. Further that all such CPAs hold a valid and unrevoked license or permit to practice as a certified public accountant or
its equivalent, issued by another state, a territory of the United States, or the District of Columbia. Also, no such CPA has been
convicted of a felony under the laws of the United States, any state, a territory of the United States, or the District of Columbia
and no such CPA has ever been convicted of a crime, an essential element of which is dishonesty, deceit, or fraud unless the
jurisdiction in which the individual is licensed has determined that the felony or other crime has no effect on the individual’s
license.
I
am submitting this notification to request authorization for our CPA firm to offer to render or to render professional services in
North Carolina. All CPAs in our firm consent to the discipline of practice privileges including, but not limited to, the revocation of
practice privileges for any violation(s) of the statutes or accountancy regulations of North Carolina and for any act which would
be cause for discipline if carried out by a licensee of North Carolina, or fraud or deceit in obtaining such privileges. We consent
to the personal and subject matter jurisdiction and disciplinary authority of the North Carolina State Board of CPA Examiners.
We consent to the appointment of the Board of Accountancy of our principal place of business which issued our certificates
and/or licenses/permits to be the agent upon whom process may be served in any action against us or our firm. We consent that
any change in standing of our CPA certificates and/or licenses/permits shall result in the immediate withdrawal of practice
privileges in North Carolina. The information contained in this notification is true and correct, and we shall amend this notification
within 30 days of any change in the information provided herein.
I
declare under penalties of perjury that the information, statements, and any attachments made in conjunction with this
application are true, correct, and complete.
Supervising CPA’s Signature Date
