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

2014 Annual Registration / CPE Report

Payment of $135 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*:

Check all appropriate boxes: (Required)
I do not hold out as a CPA or LPA in ND (credential is not used in any public manner). Sign and return form with $85. CPE detail not required.
I hold out as a CPA or LPA in ND and perform accounting, auditing, management or financial advisory, consulting, bookkeeping, or tax services, for a client or an employer’s client. Sign and return form with $85 and CPE detail.
I practice public accounting in ND, 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. You should have a firm permit (call 800-532-5904).
All others who in any way hold out as a CPA or LPA in ND. Sign and return form with $85 and CPE detail.

[Exemption for this category] I agree to include “inactive” when using the CPA / LPA title; CPE is not mandated. Sign & return with fee.

CPE Detail
Non-residents (not applicable for WI, NY, or VI) may skip this section if you meet your home state CPE rules (public practice rules, if in public practice in ND). 
Insert your home state: .
Course Title
Date(s)
Location
Sponsor
Credits
   
Total: 7-1-13 through 6-30-14
   
Total: 7-1-12 through 6-30-13
   
Total: 7-1-11 through 6-30-12
   
3 year Total (7-1-11 to 6-30-14)
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: