Application Form For Initial Permit To Practice As A Cpa In Kansas
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2REV. 04/16
(PRINT OR TYPE)
STATE OF KANSAS
BOARD OF ACCOUNTANCY
900 SW JACKSON, SUITE 556S
TOPEKA, KS 66612-1239
(785/296-2162)
APPLICATION FOR INITIAL PERMIT TO PRACTICE AS A CPA IN KANSAS
ALL QUESTIONS MUST BE ANSWERED BEFORE APPLICATION WILL BE CONSIDERED.
FAXED COPIES WILL NOT BE ACCEPTED.
NAME TO BE LISTED IN OUR RECORDS: __________________________________________________________
KS CPA CERTIFICATE NO.: ___________
(IF LAST NAME DIFFERENT WHEN CERTIFIED, ATTACH LEGAL DOCUMENTATION.)
DATE ISSUED: ______________________
SOCIAL SECURITY NO.: _________________________________________________________________________
ISSUED BY:
EXAM
RECIPROCITY
PURSUANT TO 5 U.S.C. 552a, THE KANSAS BOARD OF ACCOUNTANCY ADVISES YOU THAT SOCIAL SECURITY NUMBERS PROVIDED TO THE BOARD,
PURSUANT TO K.S.A. 74-148 AND 74-139, MAY BE PROVIDED TO THE KANSAS DEPARTMENT OF REVENUE, UPON REQUEST, OR MAY BE USED FOR
CHILD SUPPORT ENFORCEMENT PURPOSES.
CURRENT EMPLOYER: _______________________________________________________________________________________________________________
TITLE ______________________________________________________________________________________________________________________________
ADDRESSES: BUSINESS: ____________________________________________________________________________________________________________
(STREET/P.O. BOX)
(CITY)
(ST)
(ZIP CODE+4)
RESIDENCE: _____________________________________________________________________________________________________________
(STREET/P.O. BOX)
(CITY)
(ST)
(ZIP CODE+4)
PREFERRED MAILING ADDRESS: BUSINESS
RESIDENCE
PREFERRED EMAIL ADDRESS:____________________________________________________BUSINESS
PERSONAL
TELEPHONES: BUSINESS: ___________________________
FAX: ___________________________
RESIDENCE: ___________________________
1. I AM APPLYING FOR A PERMIT CLAIMING NON-ATTEST EXPERIENCE ONLY:
YES
2. I AM APPLYING FOR A PERMIT CLAIMING ATTEST AND NON-ATTEST EXPERIENCE:
YES
(SEE DEFINITIONS ON CERTIFICATE OF EXPERIENCE INSTRUCTION SHEET)
3. I AM APPLYING FOR A PERMIT CLAIMING ATTEST EXPERIENCE ONLY:
YES
NOTE: IF YOU ARE OR WILL BE SUPERVISING ATTEST SERVICES, SIGNING OR AUTHORIZING PERSONS TO SIGN A REPORT ON ANY
AUDIT, REVIEW, OR EXAMINATION OF PROSPECTIVE FINANCIAL INFORMATION ON BEHALF OF A FIRM, YOU ARE REQUIRED TO MEET
THE REQUIREMENTS SET FORTH IN THE STATEMENT OF QUALITY CONTROL STANDARDS: THE PERSONNEL MANAGEMENT
ELEMENT OF A FIRM'S SYSTEMS OF QUALITY CONTROL-COMPETENCIES REQUIRED BY A PRACTITIONER-IN-CHARGE OF AN ATTEST
ENGAGEMENT. INTERNSHIPS MAY NOT BE USED TOWARD THE EXPERIENCE REQUIREMENT.
4. IF YOU ARE NOT EMPLOYED BY A PUBLIC ACCOUNTING FIRM, ARE YOU PRESENTLY PROVIDING SERVICES
YES
NO
AS A CPA FOR KANSAS CLIENTS?
4. ARE YOU A U.S. CITIZEN?
YES
NO
(IF NOT, ATTACH A RECENT PHOTOGRAPH OR OTHER DOCUMENTATION THAT SUFFICIENTLY IDENTIFIES YOU ALONG WITH
A COPY OF YOU ALIEN REGISTRATION.
5. HAVE YOU EVER HAD A CPA CERTIFICATE CANCELED, REVOKED, SUSPENDED, REFUSED TO BE RENEWED, OR
VOLUNTARILY SURRENDERED? (If yes, attach full explanation.)
YES
NO
6. HAVE YOU EVER BEEN CONVICTED OF A FELONY, OR ANY CRIME, OF WHICH AN ESSENTIAL ELEMENT WAS
DISHONESTY, DECEIT OR FRAUD, UNDER THE LAWS OF ANY STATE OR OF THE UNITED STATES?
YES
NO
(If yes, attach full explanation.)
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