215 N 3rd Street, Suite 202C
Grand Forks, ND 58203
Tel: 800-532-5904 or 701-775-7100
ndsba.nd.gov
pdemaster@nd.gov

 

2021 Annual Registration / CPE Report

Payment of $185 required.
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:
ND CPE Certificate #*:
Email Address*:
Check all appropriate boxes: (Required)
	I have had a certificate, license, practice privilege, or permit cancelled, revoked, suspended, or not renewed in any state or jurisdiction for any cause.
	I have had my right to practice public accountancy revoked or suspended in any state or by a federal agency.
	I have been a party to a civil suit, bankruptcy action, administrative proceeding, or binding arbitration, the basis of which was grounded upon an allegation of dishonesty, fraud, or gross negligence in the performance of services as a certificate holder or licensee, or in the filing or failure to file the your own income tax returns.
	I have been convicted of a felony, or of any crime an element of which is dishonesty or fraud, under the laws of the United States, State of North Dakota, or of any other state.
Check all appropriate boxes and follow prompts: (Required)
	I do not hold out as a CPA or LPA in ND. Sign and submit form with fee. Listing CPE is optional.
	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 submit form with fee and CPE detail. I practice public accounting in ND, or intend to:   as part of a firm firm name, if not listed above:   on my own, list firm name: I provide other services for clients under my own auspices, while using the CPA/LPA title. Call the Board RE: firm permit (800-532-5904).
	All others who hold out as a CPA or LPA in ND. Sign and return form with fee and CPE detail.
ATTESTATION: I hereby certify and affirm that I have successfully completed the required hours of continuing education during the licensing period of July 1, 2020 through June 30, 2021. If audited, I agree to provide documentation that verifies I have met the requirements as claimed. If the North Dakota State Board of Accountancy concludes that I have not complied with the requirements set forth in N.D.A.C. § 3-03-01, I hereby agree to waive my right to an administrative hearing and appeal pursuant to N.D.C.C. Ch. 28-32 and agree that the Board may issue an order taking disciplinary action against my license. The information contained in this application is true and correct to the best of my knowledge. I understand that under the North Dakota Century Code 43-02.2-09(1)(a) providing false information is grounds for disciplinary action against my certificate to practice public accountancy.
Initals* (Required):

Ethics CPE Detail
Course Title	Date(s)	Location	Sponsor	Credits

CPE Detail Non-residents: Listing CPE is optional, if you meet your home state CPE rules (public practice rules, if in public practice in ND).  Insert your home state (where you meet CPE rules): .
Course Title	Date(s)	Location	Sponsor	Credits
		Total: 7-1-20 through 6-30-21
		Total: 7-1-19 through 6-30-20
		Total: 7-1-18 through 6-30-19
		3 year Total (7-1-18 to 6-30-21)

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 an accounting certificate, permit, or other accounting designation.
Signature:
Date:

" Notice: A percentage of renewal applications may be randomly selected for an audit of compliance with continuing education requirements. If selected, you must submit copies of certificates or other acceptable proof that you satisfied the continuing education requirements as you have stated on this application. You are required to save your documents so you can respond to audits. Licensees unable to comply with the audit may be subject to disciplinary action against your certificate
Please print a copy for your records BEFORE hitting Submit