07/2009
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
RECIPROCAL NC CPA CERTIFICATE
Attached is an application for a reciprocal North Carolina CPA certificate. To ensure that you have enclosed all
necessary information and that the forms are completed correctly, please review the list below before returning
the package to the Board. Please keep a copy of all documents for your reference. To obtain licensure in North
Carolina, you must complete each form, regardless of how long you have been licensed as a CPA in another
jurisdiction.
NOTE: This application is necessary only if you reside, plan to reside, or if your principal place of business
is in North Carolina.
Application Form
Did you answer all questions?
Did you sign and date the application?
Is the application notarized?
(see example)
Did you attach a recent passport-type photograph?
Did you enclose a copy of the completion/attendance certificate for the accountancy law course?
Did you enclose a $100.00 check (payable to the NC State Board of CPA Examiners) or $100.00 credit card
authorization?
NOTE: If you were not born in the United States, please provide one of the following: 1) proof of US
citizenship, 2) proof of resident alien status, or 3) a notarized statement of your intention to become
a US citizen (available from the Board’s web site, www.nccpaboard.gov).
If your name on your application documentation is different from the name you are using on your
application, please provide legal proof of your name change (marriage license, divorce decree, etc.)
Interstate Exchange Form
must be completed by the board of accountancy that issued your original
certificate and/or license. Please note that you must be currently licensed to practice public accounting by a
jurisdiction before North Carolina can grant reciprocity. Exam scores must be verified by the jurisdiction in
which you sat for the Uniform CPA Exam, even if you were certified/licensed in another jurisdiction. If you need
more than one interstate exchange form, you may make copies or print additional copies from the Board’s web
site, www.nccpaboard.gov.
CPA Firm Registration
If you are in the public practice of accounting as defined in 21 NCAC 08A .0307 and .0308 and the CPA firm
through which you are providing services has a North Carolina office, you must register that CPA firm with the
Board. CPA firm registration forms are available from the Board’s web site, www.nccpaboard.gov.
Temporary Permit
You will be issued a temporary permit prior to the issuance of your reciprocal certificate if
you submit the Reciprocal Application and payment of $100.00. Allow at least two (2) weeks for processing the
temporary permit. You must apply for reciprocity by submitting proof of completion of the accountancy law
course, the interstate exchange form completed by the jurisdiction which issued your original certificate, and by
a jurisdiction that proves current licensure. All documentation to complete the Reciprocal Application must be
received within 90 days of the date of issuance of your temporary permit. Failure to complete the reciprocal
application process will result in the expiration of the temporary permit to practice 120 days after issuance of
the temporary permit. You must then reapply and must pay the application fee again.
NOTE: Temporary permits are valid for four (4) months and are non-renewable.
Page 2 of 7
07/2009
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
ACCOUNTANCY LAW COURSE REQUIREMENT
Pursuant to 21 NCAC 08F .0504 and 21 NCAC 08H .0101(a), all CPA certificate applicants and reinstatement
applicants must complete a qualified accountancy law course on the North Carolina Accountancy Law
(Statutes) and Administrative Code (Rules).
To satisfy the requirement, an applicant must complete the course within one year preceding the date the
Board receives his or her application. For example, those planning to apply in January of the current year must
wait until after January of the previous year to take the course. If an applicant meets the requirement
prematurely, the course will not count for certification or reinstatement. The Board suggests that an applicant
take the course within a few months prior to submitting his or her application to the Board.
For new CPA certificate applicants, the course will qualify for eight (8) CPE credit hours that may be reported
on the CPE renewal form if completed during the same calendar year in which the certificate is granted.
The North Carolina Association of CPAs (NCACPA) course, "NC Accountancy Law Course: Ethics Principles
and Professional Responsibilities," is a qualified course that is available in two formats: an 8-hour group study
seminar and an 8-hour self-study course.
"NC Accountancy Law Course: Ethics, Principles, and Professional Responsibilities"
NCACPA
PO Box 80188
Raleigh, NC 27623-0188
(919) 469-1040
(800) 722-2836
www.ncacpa.org
For a list of course dates and locations, visit the NCACPA’s web site, www.ncacpa.org, and click on
“CPE & Events,” then click on “Ethics.”
PLEASE NOTE THAT THE BOARD DOES NOT OFFER THESE COURSES.
Page 3 of 7
07/2009
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
APPLICATION FOR RECIPROCAL NC CPA CERTIFICATE
NOTE: APPLICATION WILL NOT BE PROCESSED UNLESS ALL FIELDS ARE COMPLETE
First Name Middle Name Last Name Jr./Sr./III
City/State of Birth Date of Birth (MM/DD/YYYY)
Social Security Number Home E-mail Address
Home Address City/State/ZIP
Home Telephone Home Fax
Business/Firm Name
Business Address City/State/ZIP
Business Telephone Business FAX
Business E-mail Address Job Title
Send mail to: [ ] Home [ ] Business
OCCUPATION - (Check one)
[ ] Individual Practitioner [ ] Educator [ ] Govt-Non-Accounting
[ ] CPA Firm-Partner [ ] Industry-Accounting Field [ ] Law
[ ] CPA Firm-PC Shareholder/PLLC Member [ ] Industry-Non-Accounting [ ] Student
[ ] CPA Firm-Staff [ ] Govt-Accounting [ ] Unemployed
AREA OF CONCENTRATION - (Check one)
[ ] General Accountancy [ ] Auditing [ ] Financial Planning
[ ] Taxation [ ] Advisory Services [ ] Non-Accounting
[ ] Administration [ ] Law
Check the memberships you hold in the following organizations:
[ ] North Carolina Association of CPAs [ ] American Institute of CPAs
LICENSE INFORMATION
I hold CPA certificate number
dated
from the Board of Accountancy and I am under no discipline by that board. I hold a
license/permit from that board for the period ending
which allows me the unrestricted privilege to
use the CPA title and to practice public accountancy in that board’s jurisdiction.
EXAM INFORMATION
Yes No I passed all sections of the Uniform CPA Examination with a minimum score of 75 as reported by the AICPA
Advisory Grading Service.
Attach
passport-
type photo
here
Page 4 of 7
07/2009
NORTH CAROLINA ACCOUNTANCY LAW COURSE
Completion date (Attach copy of certificate of completion):
MORAL CHARACTER DATA
If you answer "Yes" to any of the questions below, you must provide a certified copy of the court records or a certified copy of applicable
license or disciplinary records with a statement of explanation with this application.
Have you been charged, arrested, convicted, found guilty of, or pleaded nolo contendere to any criminal offense
(excluding non-criminal traffic infractions)?
Y N
Have you had an application for certificate or license denied or certificate or license suspended, canceled, or revoked
by any state or federal agency or governing or licensing board?
Y N
Have you been investigated, charged, or disciplined; or are you currently under investigation by a governing or licensing
board or by a state or federal agency?
Y N
Have you been party to any civil suit, bankruptcy action, administrative proceeding, or binding arbitration; the basis of
which is grounded upon an allegation of negligence, dishonesty, fraud, misrepresentation, or incompetence?
Y N
APPLICATION FEE
Enclose check (payable to the NC State Board of CPA Examiners) or credit card authorization for $100.00.
AFFIDAVIT OF APPLICANT
I have read General Statutes Chapter 93 and Title 21, North Carolina Administrative Code, Chapter 8 and do understand the law and
rules of the Board applicable to all certified public accountants, particularly those about Professional Ethics and Conduct, and, the
Continuing Professional Education requirements. As far as I am able to determine, I meet all of the requirements to apply for a North
Carolina CPA Certificate. I understand the contents of applications including all attachments and disciplinary actions or consent orders
regarding me are subject to the NC Public Records Act. I understand that I am waiving any claim of confidentiality or privacy regarding
disclosure of such public records. I authorize the Board to make such investigative inquiries it deems necessary and release from
liability all parties responding to such inquiries. I affirm under the penalties of perjury that the information, statements, and any
attachments made in conjunction with this application are true, correct, and complete.
Signature Date
State
County
Sworn to (or affirmed) and subscribed before me this day by .
[I have personal knowledge of the identity of the principal(s)] OR [I have seen satisfactory evidence of the principal’s identity, by a
current state or federal identification with the principal’s photograph in the form of a
]
OR [a credible witness has sworn to the identity of the principal(s) ]
.
Notary Public Signature
Notary Public Printed Name
Date
My Commission Expires
Page 5 of 7
07/2009
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
AUTHORIZATION FOR INTERSTATE EXCHANGE
OF EXAMINATION & LICENSURE INFORMATION
TO THE APPLICANT: This form is essential to the application you are filing with this Board. Before your application will
be considered for approval, certain information must be verified by the board of accountancy where your examination
credits and/or certificate and license status were established. Please complete the initial portion of this form and forward
the form to the board of accountancy where credits and/or status were established with a self-addressed, stamped
envelope. That board, in turn, will complete the remainder of this form (Sections A-D) and return it to you. You are advised
to check with that board before forwarding this form to determine if there are additional requirements and/or fees charged
before such information will be released.
TO BE COMPLETED BY THE APPLICANT:
First Name Middle Name Last Name Jr./Sr./III
Mailing Address Certificate #, if Applicable
City State ZIP
( )
Daytime Phone Number Date of Birth Social Security Number
I hereby request and authorize the
Board of Accountancy to provide any and all
pertinent information requested in this form to the North Carolina State Board of Certified Public Accountant Examiners to
accompany an application filed with that agency. I agree that the State Board may confirm the grades issued to me by the
Advisory Grading Service of the American Institute of Certified Public Accountants.
Applicant Signature Date
FOR ACCOUNTANCY BOARD USE ONLY
The information provided herein is correct to the best of our knowledge.
Board/Agency
OFFICIAL
BOARD Official Signature
SEAL
Title Date
Page 6 of 7
07/2009
SECTIONS A THROUGH D ARE TO BE COMPLETED BY THE BOARD OF ACCOUNTANCY ONLY
SECTION A: VERIFICATION OF EXAMINATION CREDITS
The following are grades awarded on the Uniform CPA Examination(s) for the applicant named above, as reported by the
AICPA Advisory Grading Service and approved unchanged by this Board. Please use Section D of this form to explain if
any of the grades were changed; if an exam other than the Uniform CPA Exam was used; or if there is any reason why
the grades should not be accepted. If separate sheets are attached, please affix official signature and board seal to each
sheet.
Please list all grades, including failing grades, recorded for applicant.
Date
of Examination
AICPA
ID Number
AUD
Auditing
BEC
(LPR/Law)
FAR
(FARE/Theory)
REG
(ARE/Practice)
1) Was the applicant ever denied admission to the Exam? ( ) Yes ( ) No
If yes, please use Section D of this form to explain.
2) If the applicant has not completed the CPA Exam, are there any restrictions preventing him/her from sitting
in your jurisdiction? (Use Section D to explain.) ( ) Yes ( ) No
3) Number of subjects with which candidate is credited, if any.
Number ( ) N/A
4) Date credits or grades expire, if any.
SECTION B: CERTIFICATE/LICENSURE (Permit) STATUS
Certificate as a Certified Public Accountant:
1) The applicant holds original CPA Certificate number
dated / / which is in good standing
unless otherwise noted in Section D of this form.
2) The applicant holds reciprocal CPA Certificate number
dated / / which is in good
standing unless otherwise noted in Section D of this form.
License/Permit to Practice Public Accounting:
(If licensing is the responsibility of another agency, please forward and request completion of applicable section.)
3) The applicant holds a license/permit from this board for the period ending / /
and is currently in good
standing in this State. (Please note any exceptions to the above statements in Section D of this form.)
4) If the applicant does not hold a license/permit from your board, please indicate the requirements to be met for
issuance or reinstatement:
License/Permit not required ..........................................................
Pay appropriate fees and/or post bond .........................................
Complete acceptable accounting/auditing experience .................
Complete continuing professional education requirements ..........
Other (please specify)
5) Has there ever been any disciplinary action instituted against the applicant? ( ) Yes ( ) No
If yes, please explain in Section D.
SECTION C: ADDITIONAL INFORMATION REQUESTED: If CPA Certificate is valid and unrevoked, but a license to
practice public accountancy is not held, may applicant refer to himself as a "CPA" in your state? ( ) Yes ( ) No
SECTION D: EXCEPTIONS NOTED OR EXPLANATIONS OF INFORMATION PROVIDED (Official Seal and Signature
must be affixed to any attached sheets if needed to respond to this inquiry.)
Page 7 of 7
07/2009
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
CREDIT CARD PAYMENT
Credit card payment cannot be processed unless all fields below are complete.
MasterCard VISA Amount $
Account Number
Card Security Code
Expiration Date
(located on back of card in/near signature box) (Month/Year)
Exact Name on Card
Billing Address for Card
Street Address/PO Box City/State/Zip Code
Signature
Date
FOR BOARD USE AUTHORIZATION CODE
PROPER COMPLETION OF NOTARIAL CERTIFICATE
(A) State
(B) County
Sworn to (or affirmed) and subscribed before me this day by (C) .
(D-1) [I have personal knowledge of the identity of the principal(s)]
(D-2) [I have seen satisfactory
evidence of the principal’s identity, by a current state or federal identification with the principal’s
photograph in the form of a(n) (D-2a) [a credible witness has sworn to the
identity of the principal(s) (D-3) .]
(E)
Notary Public Signature
(F) (G)
Notary Public Printed Name
(H)
Date
My Commission Expires (I)
A. The state in which the notarial act was performed
B. The county in which the notarial act was performed
C. The name of the person (principal) whose signature is notarized (must appear in person before
the notary and sign the document in the notary’s presence)
D. The manner in which in the notary verified the identity of the principal (unused verification
should be marked through by notary)
1. Through personal knowledge of the principal or
2. By evidence of a current document issued by a federal, state, or federal or state-
recognized tribal government agency that has the individual’s photo and signature or a
physical description of the person).
2a The document that was used to identify the person (such as a NC Driver’s
License).
3. The name of a credible witness (an impartial person known to the notary) who swears
or affirms the identity of the principal. (To be used only if the principal is not known to
the notary and if the principal does not have verification of his/her identity.)
E. The notary should mark out the verification that was not used.
F. Signature of the notary (must exactly match the name in the seal & must be by hand & in ink)
G. Sharp, legible, permanent, and photographically reproducible image of the official seal
(NCGS 10B-24)
I. Printed name of the notary (must exactly match the name in the seal & may be typed or
printed)
H. The date the notarial act was performed
I. The date the notary’s commission expires
SEAL
PROPER COMPLETION OF NOTARIAL CERTIFICATE
NC State
Wake County
Sworn to (or affirmed) and subscribed before me this day by Janie Applicant
. [I have personal
knowledge of the identity of the principal(s)] [I have seen satisfactory evidence of the principal’s
identity, by a current state or federal identification with the principal’s photograph in the form of a(n)
NC DRIVER’S LICENSE [a credible witness has sworn to the identity of the principal(s)
.]
James Q. Notary
Notary Public Signature
James Q. Notary
Notary Public Printed Name
12/31/2005
Date
My Commission Expires 02/12/2009
James Q. Notary
Notary Public
Wake County, NC
