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
Original CPA Certificate Applicant Reinstatement of CPA Certificate Reissuance of CPA Certificate
Full Name (First/Middle/Last/Suffix)
Mailing Address (Street or PO Box)
City, State, Zip Code
REMAINDER TO BE COMPLETED BY CPA SIGNING FORM (Please print legibly using blue or black ink.):
INSTRUCTIONS: NCGS 93-12(5) requires applicants for the CPA certificate to have good moral character. CPAs
completing this form are asked to evaluate and comment upon the applicant's character, conduct, social relations, and
adherence to general principles of right conduct. A CPA is expected to hold a high sense of duty to his/her fellow man and
to society in general because of the amount of trust and confidence that will be placed in him/her by clients and by the
citizens of this State and Nation.
Suggested references must be CPAs and may include, but are not restricted to, instructors/professors, employers, fellow
employees, fellow NCACPA chapter members, neighbors, and public officials. The Board will not accept references from
persons related by blood or marriage to the applicant. Persons signing moral character certificates are expected to have
known the applicant for a sufficient period of time to make an evaluation of his/her moral character and to be familiar with
the applicant's lifestyle outside of the classroom or workplace. Persons signing this form should do so only after careful
consideration, and only after reviewing the properly completed application package to determine that the applicant has
made all required disclosures.
NOTE: Persons completing this form who reside and/or work in North Carolina must be licensed by this Board to
use the CPA title. Completion of this form is considered to be use of the CPA title. Persons not licensed by this
Board and living outside of North Carolina who complete this form must be currently licensed by another board
of accountancy.
I have personally known the applicant for years, months.
Describe in detail the opportunities you have had to evaluate the applicant (Attach additional page if needed).
Is the applicant of good moral character (i.e. has a personal history of honesty, fairness and respect for the rights of others
and for the laws of the State of North Carolina and this nation) and would be expected to conscientiously observe the high
professional responsibilities of a Certified Public Accountant? Y N If no, please explain (Attach additional
page if needed.):
Is the applicant entirely worthy of the trust placed in him/her by the State of North Carolina and the public as a Certified
Public Accountant? Y N If no, please explain (Attach additional page if needed.).
Page 2 of 2
To the best of my knowledge, the applicant has never been convicted, found guilty of, received a prayer for judgment
continued, or pleaded nolo contendere to any criminal offense (excluding non-criminal traffic infractions). Y N
If no, please explain (Attach additional page if needed.):
Other Comments:
If you have any questions about the applicant's moral character that are not fully explained on this form, or if the applicant
has disclosed arrest or conviction records, or license denial, suspension, or revocation by any licensing agency, the
person signing this certificate should review the documents to be supplied to the Board with the applicant's application and
send a confidential letter outlining any opinions you have concerning these matters to: Licensing Section, North Carolina
State Board of CPA Examiners, PO Box 12827, Raleigh, NC 27605. Please consider sending such correspondence by
certified mail to ensure its receipt. The Board of CPA Examiners and its staff may communicate with the person signing
this form.
I affirm under the penalties of perjury that the information, statements, and any attachments made in conjunction with this
certificate of moral character are true, correct, and complete.
Date: Signature:
NOTE: If your residence or office is in North Carolina, you cannot sign this form unless you are licensed by this
(Please print legibly using blue or black ink.)
Reference Name:
Street/PO Box:
City/State/Zip Code:
Daytime Telephone:
Email Address:
CPA Certificate Number and Issuing Jurisdiction:
Signed and sworn to (or affirmed) before me this day by
(Name of Person Providing Moral Character Reference)
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: