New Hampshire Board of Accountancy

NH Board of Accountancy
78 Regional Drive
Building Two
Concord NH 03301

(P) 603-271-3286 (F) 603-271-8702
TDD Access: Relay NH 1-800-735-2964
E-mail: boa@nh.gov

APPLICATION FOR A CERTIFICATE AS A CERTIFIED PUBLIC ACCOUNTANT
(FOR THOSE WHO HAVE SAT FOR THE EXAM IN NH)

To the New Hampshire Board of Accountancy:

I hereby make application to be certified as a certified public accountant by the New Hampshire State Board of Accountancy under the rules adopted by the Board of Accountancy and in conformity with revised statutes annotated, chapter 309-B.

The following information supports my qualifications to become certified under RSA 309-B and Board rules.

1. Full Name

Social Security Number

2. Maiden Name

Date and Place of Birth

3. Residence Address

Street:

City: State: Zip Code:

Province: Country: Mailing Code:

Phone No.

Mailing address if different than residence (If business, name of business)

Full Name:

Name of Business:

Street:

City: State: Zip Code:

Province: Country: Mailing Code:

4. Current Employer

Phone No.

5. When did you pass the CPA exam?

6. Have you ever been expelled or suspended from any professional society? Yes No.

7. The following information must be received by the Board or your application will be considered incomplete

The fee of $225.00; and
This form completed as instructed; and
Three reference letters from someone who has known you for three or more years and who you are not related to or employers. Print out three copies of the “Recommendation Form” provided.
Verification of your public accounting experience to satisfy the requirements. You must print out and use each of the following provided forms that are applicable: “Employment Verification,” “Full Time Public Accounting Experience” and/or “Part Time Public Accounting Experience.”

8. Public Accounting Experience. List in chronological order and submit letter/s on the “Employment Verification” and “Public Accounting Experience” provided.

Position Title Employed
From Employed To Name of Employer Employer Address

9. List 3 Personal References. Submit letters, using the “Recommendation Form” provided, from 3 people who have known you 3 or more years and who are not employers or related.

Name Occupation Address Years Known

Have you ever been convicted of a felony or misdemeanor or, declared by a court of competent jurisdiction to have committed any fraud? Yes No. If yes, please attach a separate sheet which contains a complete description of the circumstances.

I attest that the information contained in this application is true and correct to the best of my knowledge and belief:
Signature of Applicant	Date

On this day of , 20, in the state and county aforesaid there appeared before me who is well known to me, and who signed the above application and who being duly sworn, declared that the statements therein made were true and correct to the best of their knowledge and belief.
My Commission Expires:	NOTARY PUBLIC/JUSTICE OF THE PEACE

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Certification