INSTRUCTION SHEET LICENSED CERTIFIED PUBLIC …Additional application forms can be downloaded from the IDFPR Web site at . LICENSED CERTIFIED PUBLIC ACCOUNTANT ACCEPTANCE OF EXAMINATION

Packet Updated 4/10/20DPR-LCPA (Instructions Revised 11/16)

INSTRUCTION SHEET

Read each of the 4 steps below in the order that they are listed, then follow the directions as they apply to you. The application which you submit is valid for three years from the date of receipt.

Step 1. Use the REFERENCE SHEET (CHART I) to select the appropriate Profession Name, 3 digit Pro-fession Code, Licensure Method and Fee, and record that information in PART I of the Application for Licensure and/or Examination.

Step 2. Complete all 4 pages of the Application for Licensure and/or Examination in their entirety to avoid unnecessary delays in processing.

Report all examination(s) as referenced in the instructions in Part V - Record of Examination.

DO NOT COMPLETE PART VII

Step 3. The remainder of this form contains specific instructions for each Licensure Method. Locate the instruc-tions for the Licensure Method you recorded on PART I and follow those instructions. All documents in a foreign language that are required to be submitted with an application must be accom-panied by an original, notarized translation that has been performed by a person, other than the applicant, who is fluent in both English and the language of the document(s). The translator shall certify to the above requirements as well as to the accuracy of the translation.

Step 4. If needed, a telephone number for assistance in completing the Application Package is provided on the REFERENCE SHEET.

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.com.

LICENSED CERTIFIED PUBLIC ACCOUNTANT ACCEPTANCE OF EXAMINATION ENDORSEMENT OF LICENSE RESTORATION

ACCEPTANCE OF EXAMINATION

1. If you passed the CPA examination in Illinois, the Department will automatically receive verification of your Illinois CPA certificate from the Illinois Board of Examiners (IBOE).

2. If you passed the CPA examination in another state, the Department must receive verification of your CPA cer-tificate from the other state showing that you possess qualifications substantially equivalent to Illinois. Contact the state where you hold a CPA certificate and have an official statement verifying the requirements you met to receive the CPA certificate in that state sent directly to the Department.

3. The Certification by Licensing Agency / Board (CT) must be completed by each jurisdiction in which you have been licensed.

4. The Verification of Employment / Experience (VE-PAE) must be completed by your supervisor to document at least one year of full-time experience providing any type of service or advice involving the use of accounting, audit, management advisory, financial advisory, tax, or consulting skills, or other attestation engagements which may be gained through employment in government, industry, academia, or public practice. The experience must have been gained after completing the education requirements for licensure.

The term "year" shall be 12 months with an average of at least 20 work days per month during which you were engaged in full-time employment equal to 1500 hours or more annually. If you worked part-time for more than one year, but less than four years, and gains 2000 hours of experience, you have met the equivalent of "one year of full-time experience". Verification of the experience shall be completed and signed by your designated supervisor or the authorized agent of your employer.

5. If your CPA certificate was issued more than 4 years prior to applying for licensure, you must complete the Public Accounting CPE reporting form (PA-RF) documenting not less than 90 hours of verifiable CPE, including 4 hours covering the subject of professional ethics within the 3 years immediately preceding the application for licensure.

** Verifiable CPE is objectively confirmed by a CPE sponsor, including, but not limited to, attending, developing, teaching or presenting CPE.

6. The Affidavit Social Security Number must be completed by those applicants who will never reside or work in the United States.

7. Fee payment amount is indicated on the Reference Sheet, Chart I. Fee payment must be in the form of a check or money order made payable to the Illinois Department of Financial and Professional Regulation.

8. Forward four-page application, supporting documentation, and fee payment to:

Illinois Department of Financial and Professional Regulation ATTN: Division of Professional Regulation P. O. Box 7007 Springfield, Illinois 62791

CERTIFIED PUBLIC ACCOUNTANT - PAGE 2

1. The Certification by Licensing Agency / Board (CT) must be completed by your jurisdiction of original licensure. Documentation must show that you possess qualifications substantially equivalent to this state. If your qualifi-cations were not substantially equivalent, you must document at least 4 years of experience in the performance of accountancy activities within the 10 years preceding the application for licensure. The experience must have been gained after completing the education requirements for licensure.

2. The Certification by Licensing Agency / Board (CT) must be completed by your jurisdiction of current licensure.

3. The Verification of Employment / Experience (VE-PAE) must be completed by your supervisor to document at least one year of full-time experience providing any type of service or advice involving the use of accounting, audit, management advisory, financial advisory, tax, or consulting skills, or other attestation engagements which may be gained through employment in government, industry, academia, or public practice. The experience must have been gained after completing the education requirements for licensure.

The term "year" shall be 12 months with an average of at least 20 work days per month during which you were engaged in full-time employment equal to 1500 hours or more annually. If you worked part-time for more than one year, but less than four years, and gains 2000 hours of experience, you have met the equivalent of "one year of full-time experience". Verification of the experience shall be completed and signed by your designated supervisor or the authorized agent of your employer.

4. The Affidavit Social Security Number must be completed by applicants who will never reside or work in the United States.

5. Fee payment amount is indicated on the REFERENCE SHEET, CHART I. Fee payment must be in the form of a check or money order made payable to the Illinois Department of Financial and Professional Regulation.

6. Forward four-page application, supporting documentation and fee payment to:


ENDORSEMENT OF LICENSE


IMPORTANT NOTICE: These Restoration Instructions apply only to those certified public accountants whoselicenseshavebeenoninactivestatus,orinnon-renewedstatus,forfiveormoreyears.

Ifyourlicensehasbeeninactive,orinnon-renewedstatus,forlessthanfiveyears,you should contact the Department of Financial and Professional Regulation Call Center at 1-800-560-6420 for detailed instructions on how to restore it to active status.

1. Supporting Document CT must be completed by the jurisdiction(s) where you have practiced since your Illinois license expired, if applicable. You are authorized to photocopy this form if necessary. You must direct the licensing agency/board to return document CT directly to you.

2. Use Supporting Document VE-PAE to verify employment experience since your license expired, if applicable.

3. The Affidavit Social Security Number is to be completed by only those applicants who will never reside or work in the United States. The form must be completed and submitted with the application, other required supporting documents and fee payment.

4. Supporting Document RS must be completed. If this form was not included in the application packet, you must obtain one by contacting the Department of Financial and Professional Regulation Call Center at 1-800-560-6420.

5. Submit an affidavit attesting to honorable discharge from military service after your license had expired, if appli-cable.

6. Submit proof of 120 hours of CPE obtained within three years immediately preceding application for restoration. Not less than 4 hours of the 120 hours shall be courses covering the subject of professional ethics.

7. Forward four-page application, supporting documentation and fee payment as noted on RS form to:


RESTORATION


LICENSURE METHODS AND DEFINITIONS

Following are definitions of the various methods used in issuing licenses for professionals in the State of Illinois. Some of these licensure methods may not be applicable to your profession. Refer to the enclosed instruction sheet to determine the specific licensure methods/requirements for your profession.

Licensure Methods Definition

Examination Applicanthasappliedorisrequiredtotakeandpassalloraportionofanexamscheduledand/orgivenbytheDepartmentorarepresentativeoftheDepartment.

EndorsementofLicense Originallicenseissuedinanotherstateandthatstate'srequirementsweresubstantiallyequivalenttoIllinoisrequirementsattimelicensewasissued.

AcceptanceofExamination ApplicanthastakenaNationalExam,referredtobyIllinoisstatute,inanystate.Applicantmayormaynotbelicensedinanotherstate.

Restoration ApplicanthaspreviouslybeenlicensedinStateofIllinoisandhasallowedlicensetolapselongenoughtorequirereapplication.Possibleexampassageand/orcommitteereview.

Grandfather/Waiver Applicantwillbelicensedwithoutregardtocurrentrequirementsbecausestatuteallowsthisbasedonpastqualificationandpractices(foraspecifiedtimeonly).

Non-examination Applicantislicensedbymeetingqualificationsrequiredbystatute.Thereisnoexamfortheseprofessions.Thesecanbeeitherbusinessesorindividuals.

DPR-I-DEFINE D 7/06

IMPORTANT NOTICE

Elder and Child Abuse Reporting

"PursuanttoPublicAct91-0244,effectiveJanuary1,2000,ifyouhavereasontobelievethatanadult60yearsofageorolderwhoresidesinadomesticlivingsituationwho,becauseofdysfunctionisunabletoseekassistanceforhimselforherselfhas,withintheprevious12monthsbeensubjecttoabuse,neglectorfinancialexploitation,themandatedreportershall,within24hoursafterdevelopingsuchbelief,reportthissuspiciontotheDepartmentonAging.ReportsshouldbemadetoDEPARTMENT ON AGING AT 1-800-252-8966."

_____________________________________

"PublicAct91-0244alsorequiresthatifyouhavereasonablecausetobelieveachildknowntoyouinyourprofessionalcapacitymaybeanabusedorneglectedchildyouarerequiredtoreportsuchpossibleneglectorabusetotheDEPARTMENT OF CHILDREN AND FAMILY SERVICES AT 1-800-25abuse."

DPR-I-abuse12/99

LicensedCertified 065 AcceptanceofExamination $120.00 PublicAccountant

LicensedCertified 065 EndorsementofLicense $120.00 PublicAccountant

LicensedCertified 065 Restoration SeeSupporting PublicAccountant DocumentRS

PROFESSION LICENSURE APPLICATION PROFESSION NAME CODE METHOD FEE

DPR-LCPA 4/14

CHART I - PROFESSION NAME, PROFESSION CODE, LICENSURE METHOD & FEE

REFERENCE SHEETALLFEESARENONREFUNDABLE

Departmentreservestherighttochangefeesifprevailingcircumstancesnecessitatesuchaction.

1-800-560-6420

TTY - 1-866-325-4949

Pleaseallow3weeksfrommailingyourapplicationbeforemakinganinquiryconcerningitsstatus.

CHART III - EXAMINATION DATES AND LOCATION

NOT APPLICABLE FOR PUBLIC ACCOUNTANTSENTER N/A IN PART VII b) OF APPLICATION

FOR LICENSURE AND/OR EXAMINATION

NOT APPLICABLE FOR PUBLIC ACCOUNTANTSENTER N/A IN PART VII a) OF APPLICATION


CHART II - EXAMINATION CODES AND FEES

CHART IV - SCHOOL CODES

NOT APPLICABLE FOR PUBLIC ACCOUNTANTSENTER N/A IN PART VII c) OF APPLICATION


Ifassistanceisneeded,directyourrequesttooneofthefollowingtelephonenumbers:

* * * * * REQUEST FOR ASSISTANCE * * * * *

Illinois Department of Financial and Professional RegulationDivision of Professional Regulation

ApplicationChecklistforLicensedCertifiedPublicAccountant

FOUR-PAGE APPLICATION REVIEWPartI. ApplicationCategoryInformationPartII. ApplicantIdentifyingInformationPartIII. EducationInformationPartIV. RecordofLicensureInformationPartV. RecordofExaminationPartVI. PersonalHistoryInformationPartVII. ExaminationCodingInformation(Ifapplicable)PartVIII. ChildSupportand/orStudentLoanInformationPartIX. CertifyingStatement--SignedandDatedSUPPORTING DOCUMENTSApplication Fee

Four-pageApplicationforLicensureand/orExamination

CTForm--SupportingDocumentcompletedbyoriginalandcurrentjurisdiction(ifapplicable)

VE-PAEForm--SupportingDocumentmustbecompletedverifyingatleastoneyearoffull-timeexperience

PA-RFForm--SupportingDocumentmustbecompleteddocumenting90hoursofCPEobtainedwithinthreeyearspriortoapplicationforlicensure.Note:ThisdocumentisrequiredonlyifyourCPAcertificate/licensewasissuedmorethan4yearspriortoapplyingforlicensure.

RSForm(restorationmethodonly)

Affidavit--SocialSecurityNumber(onlyforapplicantswhoresideandworkinacountryotherthantheU.S.andwhowillneverresideorworkintheU.S.)

CopyofDD214(restorationmethodonly)

Certificatesof120hoursofCPEAttendance(restorationonly)ifapplicable

IL486-1971(LCPA)09/06

Before you mail your application, check the following items to make sure your application is complete!

All supporting documents may not be required. Please refer to application instructions foryourspecificmethodoflicensure.

COMPLETED

SUBMITTED

In order for your application to be processed, ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

A. Check the box indicating the appropriate information regarding your application. Military Military Spouse Not Military Decline to AnswerMilitaryservicememberisdefinedas.“Servicemembermeansanypersonwho,atthetimeofapplicationunderthisSection,isanactivedutymemberoftheUnitedStatesArmedForcesoranyreservecomponentoftheUnitedStatesArmedForces,theCoastGuard,ortheNationalGuardofanystate,commonwealth,orterritoryoftheUnitedStatesortheDistrictofColumbiaorwhoseactivedutyserviceconcludedwithinthepreceding2yearsbeforeapplication.”Thefollowingwillbeconsideredproofofyouoryourspouse’sactivemilitarystatus:DD214,LetterofServicesignedbyUnitCommandingOfficer,orProofofServicedocumentfromtheServicemember'selectronicpersonnelportal.ProofforSpouses:MilitaryPermanentChangeofStationOrderswiththespouseidentifiedbyname;OfficialNotificationofChangeofAssignmentwithyourmarriagelicense,acertifiedDD1172verifyingmaritalstatus,oralettersignedbythecommandingofficerverifyingchangeofassignmentandthenameofthemilitaryspouse.

ThisisthefirsttimeIhavemadeapplicationforthisprofessioninIllinois.I havepreviouslymadeapplication for this profession inIllinois. However,mypreviousapplicationexpiredand Iamnowreapplying.Other:

4. PERMANENTMAILINGADDRESSSTREET CITY STATE/COUNTRY ZIPCODE COUNTY

5. BUSINESSADDRESSSTREET CITY STATE/COUNTRY ZIPCODE COUNTY

PART I: Application Category Information

4. FEE

C. CHECKBOXINDICATINGTHEAPPROPRIATEINFORMATIONREGARDINGYOURAPPLICATION

3. UNITEDSTATESSOCIALSECURITYNO.

6. MAIDEN,GIVENSURNAME,ORANYNAME(S)UNDERWHICHSUPPORTING DOCUMENTSWILLBESUBMITTED.(SEEINSTRUCTIONS#5ABOVE)

ThefollowingmaterialsarerequiredtomakeApplicationforLicensureand/orExaminationinIllinois:

1. FourpageAPPLICATIONFORLICENSUREand/orEXAMINATION.2. INSTRUCTIONSHEET,whichgivesstepbystepapplication

instructionsforyourprofession.3. REFERENCESHEET,whichgivesdetailedcodinginformationfor

yourprofession.4. SUPPORTINGDOCUMENTS,forms,and/oranyotherdocumentation

youmayberequiredtosubmitwithyourapplication.5. If thenameshownonyoursupportingdocuments isdifferent from

thatshownonyourapplication,youmustsubmitPROOFOFLEGALNAMEchange-copyofmarriagelicense,divorcedecree,affidavitorcourtorder.

1. PROFESSIONNAME

1. NAME LAST FIRST MIDDLE

8. PLACEOFBIRTH CITY STATE/COUNTRY

11. TELEPHONENUMBERWHEREYOUMAYBEREACHED

PART II: Applicant Identifying Information--You must notify the Department of Financial and Professional Regulation - Division of Professional Regulation and/or Continental Testing Service in writing, of any address changes after you filethisapplicationinordertoreceiveanyfurtherinformation.

IL486-10194/20(LT)

3. LICENSUREMETHOD2. PROFESSIONCODE

MyapplicationforthisprofessionhadpreviouslybeendeniedinIllinois.IamreapplyingsinceIhavefulfilledadditionalrequirements.

Ihavepreviouslymadeapplication for thisprofession inIllinois.However,Iamnowapplyingundernewstatutorylanguage.

2. TITLE(e.g.,M.D.,D.D.S.,etc.)

Day Year

9. DATEOFBIRTH

Month

$

B. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONSPRIORTOCOMPLETINGITEMS1THROUGH4

CarefullyfollowallstepsoutlinedontheINSTRUCTIONSHEET.Inaddition,notethefollowing:

A. Typeorprintlegiblywithblackinkonly.

B. FEES ARE NOT REFUNDABLE.C. DisclosureofyourU.S.socialsecuritynumber,ifyouhaveone,ismandatory,

inaccordancewith5IllinoisCompiledStatutes100/10-65toobtainalicense.ThesocialsecuritynumbermaybeprovidedtotheIllinoisDepartmentofPublicAid to identifypersonswhoaremore than30daysdelinquent incomplyingwithachildsupportorder,ortotheIllinoisDepartmentofRevenuetoidentifypersonswhohavefailedtofileataxreturn,paytax,penaltyorinterestshowninafiledreturn,ortopayanyfinalassessmentortaxpenaltyorinterest,asrequiredbyanytaxActadministeredbytheIllinoisDepartmentofRevenue,ortootherentitiesforverificationofidentification.

10.AGEFemaleMale

Work: (______)______ __ ________ Home:(______)______ __ ________(Area Code) (Area Code)

APPLICATIONFORLICENSUREAND/OREXAMINATION-Page1of4

12.

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.com.

7. MOTHER'SMAIDENNAME

APPLICATION FOR LICENSURE AND/OR EXAMINATION

IMPORTANT NOTICE: Completion of this form isnecessaryforconsiderationforlicensureunder225oftheIllinoisCompiledStatutes.DisclosureofthisinformationisVOLUNTARY.However,failuretocomplymayresultinthisformnotbeingprocessed.

Fax: (______)______ __ ________ Fax:(______)______ __ ________(Area Code) (Area Code)

REQUIREDE-MAILADDRESS

Graduated Received HighSchool? YesNo ORG.E.D.? Yes No1 2 3 4 5 6 7 8 9 10 11 12

Graduated? YesNo

LOCATION(CityandStateorCountry)

DATESOFATTENDANCEFROM TO

TYPEOFDEGREE EARNED

6. COLLEGEORUNIVERSITYNAME(UndergraduateandGraduate)

Month/Year

DATESOFATTENDANCEFROM TO

LOCATION(CityandStateorCountry)

Yes No

Yes No

Yes No

Yes No

Yes No

Month/YearMonth/Year

DidYouCompleteTraining?

Month/Year

Month Year

4. DATEOFGRADUATION

PART III: Education Information

1. PRELIMINARYEDUCATION(ElementaryandHighSchoolorG.E.D.Circlenumberofyearscompleted)

INSTITUTIONNAME

1 2 3 4 5 6 7 8

2. NAMEOFLASTPRELIMINARYSCHOOL ATTENDED

3. LASTPRELIMINARYSCHOOLLOCATION (City andState)

5. COLLEGEORUNIVERSITY(Circlenumberofyearscompleted)

7. SPECIALIZEDTRAINING(Residency,ProfessionalTraining,VocationalTraining,PracticalorClinicalTraining)

IL486-1019 APPLICATIONFORLICENSUREAND/OREXAMINATION-Page2of4

NA

ME (Last, First, M

I): ______________________________________________SS#: _____________________ Profession: ___________________

PART IV: Record of Licensure Information

IL486-1019

(If additional space is needed, attach a separate sheet.)

PROFESSIONNAMESTATE

StateofCurrentLicensurewhereyoumostrecentlyhavebeenpracticing.

OtherStatesofLicensure

NAME OF EXAMINATION

(If additional space is needed, attach a separate sheet.)

PART V: Record of Examination

DATE OFISSUANCELICENSENUMBER

LICENSESTATUS(Active,Lapsed,etc.)

STATE MONTH/YEAR EXAMRESULTS

(Passed,Failed,Absent)

If you have ever taken a licensure examination in Illinois or any other state for the profession for which you are now making application, you must complete the information requested below. EACH EXAMINATION ATTEMPT MUST BE SHOWN. Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.

If you have ever been licensed to practice the profession for which you are now making application, or held a related license, complete the information requested below. If you have ever held a temporary, trainee or apprenticeship license, or a permit, it must be listed here also. In addition, the INSTRUCTION SHEET enclosed with this Application package may instruct you to have Certification(s) of Licen-sure in other state(s) prepared and submitted in support of your application (contact other state(s) regarding possible fee). You must also list all other licenses held in Illinois, however, certification of licensure from Illinois is not required. Failure to disclose all licenses held may result in denial of your application or other appropriate action.

StateofOriginalLicensure

APPLICATIONFORLICENSUREAND/OREXAMINATION-Page3of4

NA

ME (Last, First, M

I): ______________________________________________SS#: _____________________ Profession: ___________________

Underpenaltiesofperjury,IdeclarethatIhaveexaminedtheapplicationandallsupportingdocumentssubmittedbymeinconnectiontherewith,andtothebestofmyknowledge,theyaretrue,correct,andcomplete.

SignatureofApplicant Date

I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. MysignatureaboveauthorizestheDepartmentofFinancialandProfessionalRegulationtoreducetheamountofthischeckiftheamountsubmittedisnotcorrect.Iunderstandthiswillbedoneonlyiftheamountsubmittedisgreaterthantherequiredfeehereunder,butinnoeventshallsuchreductionbemadeinanamountgreaterthan$50.

PART VI: Personal History Information (This part must be completed by all applicants)

PART VIII: Certifying Statement

NOYES

IL486-1019 APPLICATIONFORLICENSUREAND/OREXAMINATION-Page4of4

NA

ME (Last, First, M

I): ______________________________________________ SS#: _____________________ Profession: ___________________

1. Inaccordancewith5IllinoisCompiledStatutes100/10-65(c),applicationsforrenewalofalicenseoranewlicenseshallincludetheapplicant'sSocialSecuritynumber,andthelicenseeshallcertify,underpenaltyofperjury,thatheorsheisnotmorethan30daysdelinquentincomplyingwithachildsupportorder.Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to contempt of court.

Areyoumorethan30daysdelinquentincomplyingwithachildsupportorder? Yes No (NOTE: If you are not subject to a child support order, answer "no.")

2. Inaccordancewith20ILCS2105-15(g),"TheDepartmentshalldenyanylicenseapplicationorrenewalauthorizedunderanylicensingActadministeredbytheDepartmenttoanypersonwhohasfailedtofileareturn,ortopaythetax,penalty,orinterestshowninafiledreturn,ortopayanyfinalassessmentoftax,penalty,orinterest,asrequiredbyanytaxActadministeredbytheIllinoisDepartmentofRevenue,untilsuchtimeastherequirementofanysuchtaxActissatisfied."

Areyoudelinquentinthefilingofstatetaxes? Yes No

PART VII: Child Support and Tax Information (Every applicant is required by law to respond to the following questions)

1.Haveyoubeenconvictedoforpledguiltyornolocontenderetoanycriminaloffenseinanystateorinfederalcourt?Pleasedonotgivedetailsonminortrafficcharges,butdoincludeinformationrelatingtoDrivingWhileIntoxicated(DWI)charges.If yes, attach a personal statement describing the circumstances of the conviction and certified copies of court records of your conviction including the nature of the offense, date of discharge, and a statement from the probation or parole office. In general, a criminal conviction by itself does not usually result in denial of licensure.

2. Haveyoubeenconvictedofafelony? In general, a felony conviction by itself does not usually result in denial of licensure.

3. Ifyes,haveyoubeenissuedaCertificateofRelieffromDisabilitiesbythePrisonerReviewBoard? If yes, attach a copy of the certificate.

4. Doyounowhaveanydiseaseorconditionthatpresentlylimitsyourabilitytoperformtheessentialfunctionsofyourprofession,includinganydiseaseorconditiongenerallyregardedaschronicbythemedicalcommunity,i.e.,(1)mentaloremotionaldiseaseorcondition;(2)alcoholorothersubstanceabuse;(3)physicaldiseaseorcondition?If yes, attach a detailed statement, including an explanation whether or not you are currently under treatment.

5. Haveyoubeendeniedaprofessionallicenseorpermit,orprivilegeoftakinganexamination,orhadaprofessionallicenseorpermitdisciplinedinanywaybyanylicensingauthorityinIllinoisorelsewhere?If yes, attach a detailed explanation.

6. Haveyoueverbeendischargedotherthanhonorablyfromthearmedserviceorfromacity,county,stateorfederalposition?If yes, attach a detailed explanation.

RETURN COMPLETED FORM TO APPLICANTLICENSING AGENCY: The Illinois Department of Financial and Professional Regulation will accept other forms

ofcertificationprovidedallapplicableinformationrequestedonthisformiscontainedinthecertification.PleaserecordN/Ainareaswhicharenotapplicable.

PART I -CERTIFICATIONOFEXAMINATIONSTATUSA. Theapplicant haswritten isscheduled towritethefollowingexamination:

DateofExaminationNameofExaminationB. Theapplicanthasorwillhavewrittentheabove-namedexamination_______numberoftimes.PART II -CERTIFICATIONOFLICENSURE

C. ISSUANCEDATEOFLICENSE

A. NAMEOFPROFESSIONASITAPPEARSONLICENSE

D. EXPIRATIONDATEOFLICENSE

B. LICENSENUMBER

E. LICENSUREMETHODExamination(AdministeredinYourState) National(Name) _____________________ StateConstructed _____________________ Other(Name) _____________________EndorsementofLicense(State) _____________________AcceptanceofExaminationResults _____________________(AdministeredinAnotherState)

F. CURRENTLICENSURESTATUS G. IFLICENSEDBYEXAMINATION,RECORDSCORES

ActiveInactiveLapsedOther(Explain)____________________________________________________________________________________________________________________

TypeofExamination ScoreWritten ________Practical ________Other(Describe)_______________________________________________________ReceivednoGradeBelow ________ExaminationPeriod_____days______hours

IMPORTANT NOTICE: Completion of thisform is necessary for consideration forlicensureunder225of the IllinoisCompiledStatutes. Disclosure of this information isVOLUNTARY. However, failure to complymayresultinthisformnotbeingprocessed.

SUPPORTINGDOCUMENT

CERTIFICATION BY LICENSINGAGENCY / BOARD CT

APPLICANT: Complete the applicant section of this form then forward this form to the jurisdiction in which youarerequestingcertificationbyalicensingagency/board.Contactcertifyingjurisdictionforappropriate fee. You are authorized to photocopy this form as necessary.

3. SOCIALSECURITYNUMBER

ProfessionName ProfessionCode

4. ADDRESS STREET,CITY,STATE,ZIPCODE 5. REFERTOREFERENCESHEET.RecordprofessionnameandthreedigitprofessioncodeforwhichyouaremakingIllinoisapplication.

6. MAIDENORGIVENSURNAME 7. APPLICANTTELEPHONENUMBER(Daytime)

2. DATEOFBIRTH1. NAME LAST FIRST MIDDLE

______ - ____- ________

8a.RECORDPROFESSIONNAMEASITAPPEARSONYOURLICENSEFROMTHEJURISDICTIONTOWHICHTHISFORMISBEINGFOR-WARDED.(Ifapplicable)

8b.LICENSENUMBER(Ifappli-cable)

8c.ISSUANCEDATEOFLICENSE (Ifapplicable)

Iherebyauthorize_________________________________________________tofurnishtotheIllinoisDepartmentof

FinancialandProfessionalRegulationoritsdesignatedtestingservice,theinformationrequestedbelow.

Signature_________________________________________ Date______________________________________

NameofLicensingAgencyorBoard

AreaCode(_________)_________ ______________

Reciprocitywith(State) ________________Waiver/GrandfatherCredentialsOther(Describe)____________________________________________________________________________________________

IL486-085004/06(LT) CT-CertificationbyLicensingAgency/Board-Page1of2

MonthDayYear____/____/________

A1.NationalorotherProfessionSpecificExamination DateofExamination ___________________ (Record all available information)

ScaledScore __________________ RawScore ___________________

StandardDeviation __________________ CorrectedScore ___________________

NationalMean __________________ PercentScore ___________________

PART III -CERTIFICATIONOFEXAMINATIONSCORES

SCORE

SCORESCORE

SCORESUBJECT DATE

SUBJECT DATE

SUBJECT DATE

DATESUBJECT

PART IV -FORMALACTIONS

A2.

B. StateConstructedExamination

IcertifythattheinformationcontainedhereinistrueandcorrectaccordingtotheofficialrecordsoftheState.

IL486-085004/06(LT)

PrintName

City,State,ZIPCode

Title

Area Code ( )

Signature

Agency/BoardStreetAddress Date

TelephoneNumber

A. Istherenoworhasthereeverbeenanyformalactioncommencedagainsttheapplicant? Yes No

B. Havethereeverbeenanyformalsanctionsimposedagainsttheapplicantasamatterofpublic recordincludingbutnotlimitedtofine,reprimand,probation,censure,revocation,suspension, surrender,restrictionorlimitation?(Ifyes,attachacertifiedcopyofdisciplinaryaction.) Yes No

PART V -RECIPROCALREGISTRATIONThisstate does doesnot grantthesameprivilegeofreciprocalregistrationtoIllinoisregistrants.

SEAL

CT-CertificationbyLicensingAgency/Board-Page2of2

NA

ME (Last, First, M

I): ______________________________________________SS#: _____________________ Profession: ___________________

Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT.

Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.

IMPORTANTNOTICE:Completionofthisformisnecessaryforconsiderationforlicensureun-der225ILCS450/1et.seq.(IllinoisCompiledStatutes). Disclosure of this information isVOLUNTARY.However,failuretocomplymayresultinthisformnotbeingprocessed.

7. HaveyoubeengrantedaCertifiedPublicAccountantCertificatebytheUniversityofIllinoisortheBoardofExaminers? YesNo

If"Yes,"recordcertificatenumber Dateofissuance

3. SOCIALSECURITYNUMBER2. DATEOFBIRTH

5. PROFESSIONNAMEANDTHREEDIGITPROFESSIONCODE4. ADDRESSSTREET,CITY,STATE,ZIPCODE

6. MAIDENORGIVENSURNAME

ProfessionCode

1. NAME LAST FIRST MIDDLE

B. NAMEOFSUPERVISOR

C. SUPERVISOR'SPOSITIONORTITLEHELD

C. DATESOFEMPLOYMENT

E. APPLICANT'SPOSITIONORTITLEHELDD. CATEGORYTYPE(SELECTONE)

A. NUMBEROFHOURSWORKEDPERWEEK

B. TYPEOFEMPLOYMENT

F. GIVEAGENERALDESCRIPTIONOFWORKPERFORMEDBYTHEAPPLICANTRELATIVETOTHEDEFINITIONOF"EXPERIENCE"REFERENCEDINSECTION1420.10OFTHERULESFORTHEADMINISTRATIONOFTHEILLINOISPUBLICACCOUNTINGACT. (Ifadditionalspaceisrequired,usethereversesideofthisform.)

PART II.-APPLICANTEMPLOYMENTINFORMATION

PART I.-EMPLOYERINFORMATIONA. NAMEANDADDRESSOFEMPLOYER

Idoherebydeclarethattheinformationrecordedhereonistrueandcorrectand,thatIamauthorizedtoverifyandreleasetheaboverecordedemployeeinformation.

Complete the applicant section of this form and forward it to your employer for completion of the verification. You may be requested to further document such experience. This form is to be used for verification of experience during which you provided any type of service or advice involving the use of accounting, attest, management advisory, financial advisory, tax or consulting skills which were gained through employment in government, industry, academia, or public practice.

APPLICANT:

VERIFICATION OFEMPLOYMENT/EXPERIENCE

SUPPORTINGDOCUMENT

VE-PAE

ProfessionName

SignatureandTitle Date

IL486-1218 3/16 (PA)

Complete the remainder of this form. Form must be completed by employer where work experience was obtained.

EMPLOYER:

Full-time Part-time



From____/____/________ To ____/____/________MonthDayYear MonthDayYear

Certified Public Accountant 0 6 5

GOVERNMENT INDUSTRYACADEMIA PUBLIC PRACTICE

3. ADDRESS STREET, CITY, STATE, ZIP CODE

4. NAME OF PROFESSION Record profession name for which you are making application.

1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH

Month Day Year

5. MAIDEN OR GIVEN SURNAME

AFFIDAVITSOCIAL SECURITY NUMBER

IL486-1975 (LT) 09/06

APPLICANTS who state they cannot obtain a social security number must complete this form.

PLEASE TYPE OR PRINT

__ __ / __ __ / __ __ __ __

Profession

Disclosure of your U.S. social security number, if you have one, is mandatory, in accordance with 5 Illinois Compiled Statutes, 100/10-65 to obtain a license. The social security number may be provided to the Illinois Department of Public Aid to identify persons who are more than 30 days delinquent in complying with a child support order, or to the Illinois Department of Revenue to identify persons who have failed to file a tax return, pay tax, penalty or interest shown in a filed return, or to pay any final assessment or tax penalty or interest as required by any tax Act administered by the Illinois Department of Revenue, or to other entities for verification of identification. Please be advised your professional licensure act may also require disclosure of your social security number.

I hereby certify that I do not have a social security number because __________________________________

________________________________________________________________________________________

________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

I understand that in the event I obtain a social security number, I have the obligation to provide the Division of Professional Regulation, in writing, with the social security number within 10 days. My failure to do so may result in disciplinary action against my license.

Under penalty of perjury, I hereby declare that the above information is true and correct.

Signature Date

IL486-123207/22/05(PA)

INSTRUCTIONS

FOR PERSONS RENEWING THEIR PUBLIC ACCOUNTANT LICENSE

You are required to complete 120 hours of Continuing Professional Education (C.P.E.) which must have been acquired during the 36 months immediately preceding October 1 of the year your license expires. Not less than 4 hours of the 120 hours shall be courses covering the subject of professional ethics. If you are selected for the C.P.E. compliance audit, you will be notified to submit evidence of the qualifying hours which you have detailed on this form.

FOR PERSONS MAKING APPLICATION FOR RESTORATION OF LICENSURE AS A PUBLIC ACCOUNTANT

A person seeking restoration of a license must complete and provide satisfactory evidence of 120 hours of C.P.E. which must have been acquired during the 36 months immediately preceding submission of your application for restoration. Not less than 4 hours of the 120 hours shall be courses covering the subject of professional ethics.

SATISFACTORY EVIDENCE OF HOURS AND APPLICABLE LIMITATIONS

The following describes satisfactory evidence for each category of allowable C.P.E. and applicable limitations:

1. In-Firm courses - confirmation of attendance by the registered sponsoring firm;

2. Other programs attended - Certificate of Attendance issued by the registered sponsor. PROGRAMS OF-FERED BY NON-REGISTERED SPONSORS ARE NOT ACCEPTABLE;

NOTE: IfyouarereportingC.P.E.hoursusedforthefulfillmentofaC.P.E.requirementinanotherstate, you must list these programs on a separate sheet and staple it to this form. You must listallprograminformationasrequiredinnumber2onthefrontsideofthisform.Youmustalso provide the name and telephone number of the C.E. Coordinator in that state.

3. Correspondence or individual study programs - Certificate of Completion issued by the registered sponsor. Limitation = 60 hours: allowed on the basis of one-half of the average completion time as determined by the sponsor.

4. In addition to the limitations stated in number 3 above, not more than 80 hours during any renewal period may consist of a combination of interactive self-study and correspondence or individual study courses.

5. Publications - copy of Article(s), including copy of publication's table of contents and publication date. Publi-cation of book(s) - include a copy of the title page and the page which indicates the copyright date. Limitation = 30 hours allowed for actual time spent in writing or researching.

6. Teacher, instructor, lecturer or discussion leader - Certification by department-head of dates and courses taught or certification by registered C.P.E. sponsor of dates and C.P.E. courses taught. Limitation = 60 hours allowed for actual presentation time plus actual preparation time. Preparation time is limited to up to 2 hours for each hour of presentation. Preparation time shall not be allowed for repetitious presentations of the same course, and will only be allowed for additional study or research.

7. University or college courses - copies of transcripts confirming university courses taken and hours awarded. The hours are calculated at the rate of 15 C.P.E. hours for each semester hour or 10 C.P.E. hours for each quarter hour of school credit awarded.

TitleofPublication SubjectsCovered

NameofSponsororCollege/University CourseTitle/Subject

Semester Hours Awarded

Quarter Hours Awarded

Course

TOTAL CPE HOURS

See Reverse side of form for INSTRUCTIONS. You are authorized to photocopy this form if additional space is needed. EACH form must bear an original signature and date.

065 -

PA-RF

DateSignature

IL486-12327/05(PA)

Underpenaltiesofperjury,IdeclareIhaveexaminedthisformandallsupportingdocumentssubmittedbymeincon-nectiontherewith,andtothebestofmyknowledge,theyaretrue,correct,andcomplete.

Qualifying HoursClaimed

PUBLIC ACCOUNTINGCONTINUING PROFESSIONAL EDUCATION

REPORTING FORM

University/College

ADDRESS STREET,CITY,STATE,ZIPCODE

LICENSENUMBERNAME

1. IN-FIRM COURSES

2. OTHER PROGRAMS ATTENDED (WITH REGISTERED SPONSORS ONLY - See Item 2 on Reverse Side)

3. CORRESPONDENCE OR INDIVIDUAL STUDY PROGRAMS OR INTERACTIVE SELF-STUDY

4. PUBLISHED ARTICLES, BOOKS, ETC.

5. TEACHER, INSTRUCTOR, LECTURER, OR DISCUSSION LEADER

6. UNIVERSITY OR COLLEGE COURSE

Date(s) Name of Sponsor Title of Program

IMPORTANT NOTICE: Completion of thisform is necessary for consideration forlicensure under 225 ILCS 450/1 et. seq.(Illinois Compiled Statutes). Disclosure ofthis information is VOLUNTARY. However,failure to complymay result in this formnotbeingprocessed.

Documents

INSTRUCTION SHEET LICENSED CERTIFIED PUBLIC …Additional application forms can be downloaded from the IDFPR Web site at . LICENSED CERTIFIED PUBLIC ACCOUNTANT ACCEPTANCE OF EXAMINATION