Guam Board of Accountancy Experience Affidavit …

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: Experience Affidavit INSTRUCTIONS: If you hold a certificate issued by the guam Board and are applying for an initial permit to practice, please include your certificate number on this form. Administrative Rules provide that to be issued an initial license (permit) 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. An Attest license requires a minimum of 1,000 hours of attest Experience directly supervised by a licensee authorized to perform attest work.

2 Experience must be verified by a holder of a valid CPA license issued by one of the 55 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%): %Accounting Services %Tax/Tax Advisory Services %Audit/Attest Services %Consulting Skills %Financial Advisory Services %Management Advisory Services I certify under penalty of perjury that the representations I have made in this Experience Affidavit are true and correct: Applicant's Signature Date CPA's VERIFICATION. Name: Title: Address: CITY STATE, PREFECTURE, COUNTRY POSTAL CODE.

3 Telephone: Fax: Email: Certificate/License/Permit Number: Issuing Jurisdiction: I certify under penalty of perjury that (1) I currently hold a valid CPA license to practice public accounting; (2) I held a valid CPA license to practice public accounting in a US jurisdiction during the employment period indicated by applicant above;. (3) that applicant has obtained the Experience indicated above; and (4) the representations made in this Experience Affidavit are true and correct to the best of my knowledge. Verifying CPA's Signature Date Note: This form must be completed in its entirety to be valid. Incomplete forms will not be accepted. Page 1 of 1.