Status Change To Active Request Form - Minnesota Board Of Accountancy

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85 East 7th Place, Suite 125, St. Paul, MN 55101-2143

Ph: 651-296-7938 • Fax: 651-282-2644 • boa.state.mn.us

CLEAR

FORM

STATUS CHANGE TO ACTIVE REQUEST FORM

For Exempt to Active Change and IMMEDIATE* Inactive to Active Change

*Inactives seeking status change as of their next license renewal: Use the renewal form for that year, available when renewals open.

Return form with

$100 fee

payable to MN Board of Accountancy at the address above.

Note:

All licenses expire December 31, regardless of the date issued.

SECTION 1: APPLICANT INFORMATION

Military Only

If you are active duty or within 6 months of discharge from active duty, check box:

All Applicants

What is your preferred “mail to” address?

Home

Business

Check the appropriate box if you are:

Not currently employed

Retired

Provide Home and Work Contact Information

If you are employed/self-employed, you must include both your home and work information.

Name

(First)

(M.I.) (Last)

(Suffix)

Certificate #

Employer Name

Home Phone

Work Phone

Home Address

Work Address

City

State

Zip

State

Zip

I wish to change my status to:

Active (from Inactive status)

$100

fee. See chart page

for CPE Reporting requirements.

Active (from Exempt status)

$100

fee. See chart page

for CPE Reporting requirements.

Have you been convicted of a felony in the past year?

Yes*

If yes, include felony type, date, count, sentence and any other relevant information on a separate sheet.

Affidavit:

I swear or affirm that I have read the foregoing application and the statements are true and complete.

Signature

Date

NOTICE OF COLLECTION OF PRIVATE DATA

In accordance with the Minnesota Government Data Practices Act (MN Statute §13.04, Subd. 2), the Board is required to inform you of your rights as they

pertain to private data collected from you on this application for licensure. The data you furnish on the application will be used by the Board to assess

your qualifications for licensure. The collection of your social security number by the Board is required by both federal and state laws. You are not legally

required to provide this data; however, if you fail to do so, the Board may be unable to approve your application or issue your license.

Federal law (42 U.S.C. 666(a)(13)) requires each state to collect social security numbers at the time of application for a professional or occupational

license in order to improve effectiveness of child support enforcement.

Additionally, pursuant to Minnesota Statutes §270C.72, subdivision 4 (2016) the Board must provide the Commissioner of the Minnesota Department

of Revenue a list of all applicants, including name, address and social security number or Individual Tax Identification Number (ITIN), each calendar year

for the purpose of identifying individuals owing delinquent taxes.Pursuant to Minnesota Statutes §13.41, subdivision 2 (2016), all application data, except

name and designated address, are private data until licensure is granted. When licensure is granted, all data, except social security number, become public

record.

The Board will not share your private data with other persons or agencies unless you authorize its release or it is required by law.

Status Change to Active Request FORM—Page 1 of 3

Rev 1/18