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
EXPERIENCE AFFIDAVIT - SELF-EMPLOYED
If you are self-employed and wish to use that experience to obtain your North Carolina CPA certificate, you must provide
five (5) notarized statements from different individuals or companies who have been your clients during the same period of
time needed for certification. These individuals or companies must be able to state that you have performed accounting
work full-time for the entire period. You must also submit copies of state or local privilege licenses for the same period of
time you are using for self-employed experience. If your state, county, or municipality does not require a privilege license,
you must submit copies of the Schedule C pages of your tax returns. Copies of your individual or firm registration
documentation from another board of accountancy are not acceptable documentation of your experience. Please refer to
21 NCAC 08F .0401 for the rules on experience.
has served as my/our accountant from
Applicant’s Full Name (MM/DD/YYYY)
until (today’s date or last day of service).
(MM/DD/YYYY)
He/She has provided me/us with the following services (Please print legibly using blue or black ink. Attach additional pages
if needed.):
T
o the best of my knowledge, the applicant has performed accounting work full-time for the entire period in question.
Signature Printed Name
Date Company Name
Street or PO Box City, State, Zip Code
Telephone Number Fax
Email Address
State
County
Signed and sworn to (or affirmed) before me this day by
(Name of Person Signing Form, Not Applicant Name)
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:
