Free 48541.FH11 - Indiana

APPLICATION FOR ACTIVATION OF AN INACTIVE CPA/PA/AP LICENSE
State Form 48541 (R3 / 4-07)

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

APPLICANT INFORMATION: In order to activate an inactive license during a three (3) year license period, the licensee must complete one hundred twenty (120) hours of continuing education obtained no earlier than three (3) years prior to the date this application is filed, as required by 872 IAC 1-3-14.5. INSTRUCTIONS: 1. Complete this form in its entirety. 2. Attach proof of 120 hours of continuing education (10% Accounting and/or Auditing, 50% limit on self study, minimum of 2 hours ethics for accountants). APPLICANT INFORMATION
Name of applicant Residential address (number and street, city, state, and ZIP code) Telephone number E-mail address Date (month, day, year) License number

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Signature of applicant

CONTINUING EDUCATION INFORMATION NAME OF SPONSOR / PROVIDER COURSE NAME
(month, day, year)

DATE

3 FOR A&A

3 FOR ETHICS

3 FOR NUMBER SELF STUDY OF HOURS

TOTAL HOURS USE ADDITIONAL SHEET(S) IF NECESSARY, FOLLOWING THE SAME FORMAT.

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