APPLICATION FOR INITIAL CERTIFICATION AND ... - Guam Boa

1 guam Board of Accountancy 335 South Marine Corps Drive, Suite 101, Tamuning, GU 96913 Tel: 671-647-0813 Fax: 671-647-0816 Website: Email: Page 1 of 5 APPLICATION FOR INITIAL CERTIFICATION AND LICENSURE (NOTE: you may photocopy these forms - Altered, Changed or Retyped forms will NOT be accepted) (REVISED 11/30/11) CHECKLIST You must submit the following items with your completed, signed APPLICATION : US$ credit card, check, cashiers check or money order payable to guam BOARD OF ACCOUNTANCY A 2 x 2 passport-type photo (less than 1 year old) A copy of your government issued Personal Photo Identification (passport, driver s license, etc.) which must be in English Completed and endorsed Moral Character Reference Forms from three (3) different individuals Completed Experience Affidavit form(s) detailing 1 - 2 years' experience, verified by a Licensed CPA, as appropriate for your education level and desired license type - see form instructions for details Authorization for Interstate Exchange of Examination and Licensure Information (IF you passed the CPA exam elsewhere and/or you are licensed in a jurisdiction other than guam ) Official college transcripts detailing all courses taken.

2 Foreign transcripts must be accompanied by a foreign academic credential evaluation (transcripts and evaluations must be sent separately and directly to the Board) (IF you were a guam CPA exam candidate, you do NOT need to RE-submit transcripts, evaluations or grades) For further assistance, call 671-647-0813 or MAIL your completed APPLICATION package to: Attn: Licensing Administrator guam Board of Accountancy 335 S. Marine Corps Drive, Suite 101 Tamuning, GU 96913 APPLICANT S LEGAL NAME (Must MATCH Passport) LAST FIRST MIDDLE ADDRESS OF RECORD Home or Business STREET (include Apt # or Suite #) CITY STATE/TERRITORY/PREFECTURE/COUNTRY ZIP/POSTAL CODE CONTACT INFORMATION TELEPHONE FACSIMILE EMAIL PERSONAL IDENTIFICATION INFORMATION SOCIAL SECURITY NUMBER (If none, use Passport Number & Country) BIRTHDATE (MM/DD/YYYY) guam Board of Accountancy 335 South Marine Corps Drive, Suite 101, Tamuning, GU 96913 Tel: 671-647-0813 Fax: 671-647-0816 Website: Email.

3 Page 2 of 5 EMPLOYMENT HISTORY (List employers for the past five (5) years, use separate sheet if necessary) CURRENT EMPLOYER NAME EMPLOYED: From/To (MM/YYYY) STREET ADDRESS (include Apt # or Suite #) CITY STATE/TERRITORY/PREFECTURE/COUNTRY ZIP/POSTAL CODE TELEPHONE FACSIMILE EMAIL PREVIOUS EMPLOYER NAME EMPLOYED: From/To (MM/YYYY) STREET ADDRESS (include Apt # or Suite #) TELEPHONE/FACSIMILE CITY STATE/TERRITORY/PREFECTURE/COUNTRY ZIP/POSTAL CODE PREVIOUS EMPLOYER NAME EMPLOYED: From/To (MM/YYYY) STREET ADDRESS (include Apt # or Suite #) TELEPHONE/FACSIMILE CITY STATE/TERRITORY/PREFECTURE/COUNTRY ZIP/POSTAL CODE GOOD MORAL CHARACTER guam law requires that CERTIFICATION be granted only to persons of good moral character ( , a personal history free of dishonest or felonious acts).

4 You must answer these questions, attaching a separate page explaining any yes answers: 1. Have you ever been convicted of a felony? Yes No 2. Have you ever been convicted of a crime involving dishonesty? Yes No 3. Have you ever had a professional license or permit to practice suspended or revoked? Yes No 4. Have you ever been denied the privilege to write the CPA exam? Yes No guam Board of Accountancy 335 South Marine Corps Drive, Suite 101, Tamuning, GU 96913 Tel: 671-647-0813 Fax: 671-647-0816 Website: Email: Page 3 of 5 OTHER LICENSING INFORMATION List all certificates, licenses or permits you hold or have applied for in guam or in other states or foreign jurisdictions: Jurisdiction: License/Certificate/Permit Number: Jurisdiction: License/Certificate/Permit Number: Jurisdiction: License/Certificate/Permit Number.

5 AICPA UNIFORM CPA EXAMINATION(S) TAKEN SECTIONS and GRADES Test Center Name/Location Examination Date Candidate ID Number Auditing And Attestation Financial Accounting And Reporting Regulation Business Environment And Concepts (AUD) (FAR) (REG) (BEC) EDUCATION COLLEGES and UNIVERSITIES ATTENDED College or University Name Dates Attended Date of Degree Degree Awarded SIGNATURE DESIRED LICENSE TYPE: INACTIVE ACTIVE ATTEST NON-ATTEST I certify under penalty of perjury under the laws of guam that the statements in this APPLICATION and all accompanying documents are true and correct, and that I have not suppressed any information that might affect this APPLICATION . I understand that misrepresentation may result in denial, suspension or revocation of any CPA Certificate or License issued.

6 I further certify that I have read and agree to abide by the provisions of the guam Accountancy Act of 2003, as amended, and the guam Board of Accountancy Administrative Rules. Signature: Date: For Office Use Only: Receipt # Date: License Type: Check # Amount US$ Attest Non-Attest guam Board of Accountancy 335 South Marine Corps Drive, Suite 101, Tamuning, GU 96913 Tel: 671-647-0813 Fax: 671-647-0816 Website: Email: Page 4 of 5 Moral Character Reference guam law requires that CERTIFICATION be granted only to applicants of good moral character ( , a personal history free of dishonest or felonious acts).

7 guam Board of Accountancy rules require moral character references from three (3) different individuals, as described below. APPLICANT S LEGAL NAME LAST FIRST MIDDLE A responsible individual that is familiar with the moral character of the applicant should sign this certificate. This form should not be signed by a relative of the applicant, or by a person who maintains any financial or business relations with the applicant, except that of a client or employer. Please sign and mail directly to the above address. To be completed by the Endorsee signing this Moral Character Reference form (please include a copy of Endorsee's government issued Personal Photo Identification - passport, driver s license, etc. - in English): Name (please print or type legibly): I have known the above applicant for approximately_____ years. (minimum 2 years) My relationship to applicant is as a(n): (Employer, client, friend, other please specify) I certify that I am personally acquainted with this applicant and that to the best of my knowledge he/she has never been convicted of a felony or misdemeanor crime, or declared by any court of competent jurisdiction to have committed any fraud.

8 I know this person to be of good moral character and also to be a good citizen. I recommend this applicant as entirely worthy to be a licensed Certified Public Accountant should the other requirements prescribed by law be met. I am willing to answer any questions that you may ask in regard to the applicant and I will treat the same as strictly confidential. I certify that these statements are true and I understand that false or misleading responses may result in the denial, suspension or revocation of any CPA Certificate or License issued to applicant. Endorsee Signature Date Endorsee s Employer: Employer s Address: City: State: Postal Code: Employer s Telephone No: Fax No: Email: Note: This form must be completed in its entirety to be valid.

9 Incomplete forms will not be accepted. guam Board of Accountancy 335 South Marine Corps Drive, Suite 101, Tamuning, GU 96913 Tel: 671-647-0813 Fax: 671-647-0816 Website: Email: Page 5 of 5 Experience Affidavit INSTRUCTIONS: If you hold a certificate issued by the guam Board and are now applying for a license to practice, please include your certificate number on this form. Administrative Rules generally provide that to be issued an Active license to practice, an applicant must provide evidence of Two Years Experience (minimum of 4,000 hours) or One Years Experience plus 150 hours of education, obtained over a period of not less than one (1) year nor more than five (5) years of employment. Experience may consist of providing any type of services or advice using accounting, attest, compilation, management advisory, financial advisory, tax or consulting skills in industry, government, academia or public practice.

10 An Attest license requires a minimum of 1,000 hours of attest experience directly supervised by a licensee authorized to perform attest work. Experience must be verified by a holder of a valid CPA license issued by one of the 55 Board jurisdictions. Complete a separate form for each employer that you report work experience with. APPLICANT S LEGAL NAME (If issued, guam CPA Certificate No: ) LAST FIRST MIDDLE Employer: Title: Employer Address: CITY STATE, PREFECTURE, COUNTRY POSTAL CODE Dates Worked - From: To: Total Hours: Fulltime: Part-time: (MM/DD/YYYY) (MM/DD/YYYY) Employment In: Academia: Accounting - Public: Government: Private: My experience with this employer encompassed the following skill areas (must total 100%).