Free 49209.FH11 - Indiana

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ACCOUNTANCY APPLICATION PART I
State Form 49209 (R3 / 3-09) Approved by State Board of Accounts, 2009

INDIANA BOARD OF ACCOUNTANCY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

INSTRUCTIONS:

Please type or print legibly.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1; disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY
Application fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year) Receipt number License obtained by

DO NOT WRITE ABOVE THIS LINE
GENERAL INFORMATION
Type of application (please check one)

CPA certificate
Name of applicant (last, first, middle) Previous names used

Reciprocity certificate

Transfer of grades

Reciprocity certificate by substantial equivalency
Social Security number *

Address (number and street, city, state, and ZIP code) Date of birth (month,day, year) Home telephone number Business telephone number E-mail address

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Have you ever been convicted of: A. An act which would constitute a ground for disciplinary sanction under IC 25-1-11-5 B. A felony that has a direct bearing on your ability to practice competently If yes, please attach supporting documentation relevant to the conviction.
Date you passed the CPA examination (month, day, year) If yes, name of institution conferring degree State in which you passed the examination Date degree conferred (month, day, year)

Yes Yes

No No

Do you have an advanced degree in accounting or business administration?

Yes

No No

Do you hold a license in good standing as a certified public accountant from a state other than Indiana? Yes If yes, please complete the below table.

STATE WHERE ISSUED

LICENSE NUMBER

DATE ISSUED (month, day, year)

APPLICANT AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete, and correct.
Signature of applicant Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization, or institution to release to the Indiana Professional Licensing Agency, or the Indiana Board of Accountancy, any files, documents, records, or other information pertaining to the undersigned requested by the Agency, or the Board, or any of their authorized representatives, in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Indiana Professional Licensing Agency or the Indiana Board of Accountancy to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information, which is material to my application, and I hereby specifically release the Agency, and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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ACCOUNTING EXPERIENCE PART II
Part of State Form 49209 (R3 / 3-09) Name of applicant (last, first, middle) Social Security number *

ORIGINAL / RECIPROCAL CPA LICENSE
Name of employer Address of employer (number and street, city, state, and ZIP code) Telephone number Dates employed (month, day, year)

FOR OFFICE USE ONLY

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From

To
License number of verifier

Name of verifying licensee Address of verifying licensee (number and street, city, state, and ZIP code) Telephone number E-mail address of verifier

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Brief job description

Name of employer Address of employer (number and street, city, state, and ZIP code) Telephone number Dates employed (month, day, year)

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)

From

To
License number of verifier

Name of verifying licensee Address of verifying licensee (number and street, city, state, and ZIP code) Telephone number E-mail address of verifier

(

)

Brief job description

Name of employer Address of employer (number and street, city, state, and ZIP code) Telephone number Dates employed (month, day, year)

(

)

From

To
License number of verifier

Name of verifying licensee Address of verifying licensee (number and street, city, state, and ZIP code) Telephone number E-mail address of verifier

(

)

Brief job description

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