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
This form is a supplement to the Experience Affidavit. The direct supervisor should complete both forms and attach this
supplement to the Experience Affidavit. Please refer to 21 NCAC 08F .0409 for the rules regarding teaching experience.
You may copy this form if necessary, but each page must bear the institution’s seal and the signature of the chair of the
department or the dean of the school.
Applicant Name (First/Middle/Last/Suffix)
The applicant was teaching at this institution for the period beginning and ending (date of
termination or today’s date) . This school is on the quarter semester system and
considers a minimum of quarter semester hours per (check one) quarter semester year
as full-time teaching. Below is a listing of courses taught by the applicant.
Course Title
Printed Name Signature Date
College or University
Institution’s Seal