Fillable North Carolina State Board of Certified Public Accountant (NC State Board of CPA Examiners)

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North Carolina State Board of Certified Public Accountant (NC State Board of CPA Examiners)

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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
AUTHORIZATION FOR INTERSTATE EXCHANGE
OF EXAMINATION & LICENSURE INFORMATION
TO THE APPLICANT: This form is essential to the application you are filing with this Board. Before your application will be
considered for approval, certain information must be verified by the board of accountancy (BOA) where your Uniform CPA
Exam credits and/or certificate and license status were established. Before sending this form for completion by that entity,
contact the entity to determine if you need to meet additional requirements or pay any fees before such information will be
released.
Complete the applicant portion of this form and forward the form and a self-addressed, stamped envelope to the BOA
where credits and/or status were established. The BOA will complete the remainder of this form (Sections A-D) and return
it to you. This Board will accept another BOA’s own form as long as it provides the same information requested on this
form. Include the completed form sent to you by the BOA with the rest of your application package submitted to this Board.
TO BE COMPLETED BY THE APPLICANT:
Full Name (First/Middle/Last/Suffix)
Mailing Address (Street or PO Box and City, State, Zip Code)
Daytime Telephone Number CPA Certificate No. (if applicable)
Birthdate (MMDDYYYY) Social Security Number
I hereby request and authorize the Board of Accountancy to provide any and all
pertinent information requested in this form to the North Carolina State Board of Certified Public Accountant Examiners to
accompany an application filed with that agency. I agree that the State Board may confirm the grades issued to me by the
Advisory Grading Service of the American Institute of Certified Public Accountants.
Applicant Signature Date
FOR ACCOUNTANCY BOARD USE ONLY
The information provided herein is correct to the best of our knowledge.
Board/Agency
OFFICIAL
BOARD Official Signature
SEAL
Title Date
03-2018
SECTIONS A THROUGH D ARE TO BE COMPLETED BY THE BOARD OF ACCOUNTANCY ONLY
SECTION A: VERIFICATION OF EXAMINATION CREDITS
The following are grades awarded on the Uniform CPA Examination(s) for the applicant named above, as reported by the AICPA
Advisory Grading Service and approved unchanged by this board. Please use Section D of this form to explain if any of the grades
were changed; if an exam other than the Uniform CPA Exam was used; or if there is any reason why the grades should not be
accepted. If separate sheets are attached, please affix official signature and board Seal to all pages.
Please list all grades, including failing grades, recorded for applicant.
Date
of Examination
AICPA
ID Number
AUD
Auditing
BEC
(LPR/Law)
FAR
(FARE/Theory)
REG
(ARE/Practice)
1) Was the applicant ever denied admission to the Exam? Y N If yes, complete Section D of this form.
2) If the applicant has not completed the CPA Exam, are there any restrictions preventing him/her from sitting in your jurisdiction?
Y N If yes, complete Section D of this form.
3) Number of subjects with which candidate is credited, if any. Number N/A
4) Date credits or grades expire, if any. (MMDDYYYY)
SECTION B: CERTIFICATE/LICENSURE (PERMIT) STATUS
Certificate as a Certified Public Accountant:
1) The applicant holds original CPA Certificate number dated (MMDDYYYY) that is in good
standing unless otherwise noted in Section D of this form.
2) The applicant holds reciprocal CPA Certificate number dated (MMDDYYYY) that is in
good standing unless otherwise noted in Section D of this form.
License/Permit to Practice Public Accounting: If licensing is the responsibility of another agency, please forward and request
completion of applicable section.
3) The applicant holds a license/permit from this board for the period ending (MMDDYYYY) and is currently in
good standing in this State. Please note any exceptions to the above statements in Section D of this form.
4) If the applicant does not hold a license/permit from your Board, please indicate the requirements to be met for issuance or
reinstatement:
License/Permit not required ....................................................................
Pay appropriate fees and/or post bond ...................................................
Complete acceptable accounting/auditing experience ............................
Complete continuing professional education requirements ....................
Other (please specify)
5) Has there ever been any disciplinary action instituted against the applicant? Y N If yes, complete Section D of this
form.
SECTION C: ADDITIONAL INFORMATION REQUESTED: If CPA certificate is valid and unrevoked, but a license to practice public
accountancy is not held, may applicant refer to himself as a "CPA" in your jurisdiction? Y N
SECTION D: EXCEPTIONS NOTED OR EXPLANATIONS OF INFORMATION PROVIDED On an additional sheet, explain answers
to above questions as needed. Official Seal and Signature must be affixed to all attached sheets.
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Completed 14 August 2020

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