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
I, , acknowledge that my North Carolina CPA
Certificate number granted on (month/day/year)
was either lost or destroyed on (month/day/year). I have made a
diligent search for this certificate and have been unable to locate it. I affirm that should this
certificate be located, I will immediately return it to the Board's office at 1101 Oberlin Road,
Suite 104, Raleigh, NC 27605. I understand that it is a violation of the North Carolina General
Statutes to refer to myself as a CPA or Certified Public Accountant in the State of North
Carolina unless I am properly licensed by the North Carolina State Board of Certified Public
Accountant Examiners.
Signature: Date:
Signed and sworn to (or affirmed) before me this day by
(Name of CPA)
Witness my hand and official seal, this the _____ day of , 20 .
Official Signature of Notary
, Notary Public
Notary’s printed or typed name
My commission expires: