North Dakota
State Board of Accountancy
2701 S. Columbia Road
Grand Forks, ND 58201-6029
Tel: 800-532-5904 or 701-775-7100
www.nd.gov/ndsba
ndsba@nd.gov

Click here for questions and answers regarding this form

2012 Annual Registration / CPE Report

Payment of $125 by credit card required (Includes $50 late fee).
Fields marked with an asterisk (*) are required.

First Name*:

Last Name*:

Preferred Address

Firm Name:

Address*:

Address (continued):

City*:

State*:

Zip*:

Country*:

Home Phone:

Nonpreferred Address

Firm/Company:

Address:

Address
(continued):

City:

State:

Zip:

Other Information

Firm Phone:

Direct Phone:

Fax:

Certificate #*:

Email Address*:

Section 1. Check all appropriate boxes: (Required)

I do not hold out as a CPA or LPA in ND (i.e. credential is not used in any public manner). Sign and return form with $75. No CPE required.

I perform accounting, auditing, management or financial advisory, consulting, bookkeeping, or tax services, for a client or an employer’s client, while holding out to the public as a licensee in ND. “Holding out” includes any public use of the CPA / LPA credential, including business cards, etc. Sign and return form with $75 and CPE details.

	I practice public accounting in North Dakota (defined on back), or intend to, full time or part time:
		as part of a firm firm name, if not listed above:
		under my own auspices* (firm name: ) * If checked, you should also have a firm permit. Call 800-532-5904 for a form.
	I provide other services for clients, under my own auspices, while using the CPA/LPA title.*

All others who in any way hold out as a CPA or LPA in ND. Sign and return form with $75 and CPE details.

Section 2. CPE Exemptions (complete if appropriate)
To seek "retired status" (not employed), contact the Board.

Non-residents: If you meet your home state CPE rules (home state public practice rules apply, if you practice public accounting in ND),then insert state here ; you need not list CPE details below. This exemption is not applicable for WI, NY, VI. Sign and return form with $75.

Inactive CPE exemption: I hold out as a CPA or LPA in ND, but I do not perform accounting, auditing, management or financial advisory, consulting, bookkeeping, or tax services, for a client or an employer’s client, while holding out to the public as a licensee in ND. I agree to include the term “inactive” whenever I use the CPA / LPA title. Sign and return form with $75. No CPE required.

Section 3. CPE Report (Complete unless an exemption is checked in Section 2 above)

Course Title	Date(s)	Location	Sponsor	Credits














		Total: 7-1-11 through 6-30-12
		Total: 7-1-10 through 6-30-11
		Total: 7-1-09 through 6-30-10
		3 year Total (7-1-09 to 6-30-12)

Signature Section (Required)

I will comply with the accounting ethics codes of the AICPA, SEC and GAO whenever applicable based on the services I perform.

Following are all the other jurisdictions where I hold or have applied for a certificate, permit or other accounting designation.

Signature:

Date: