Application Packet for a Georgia CPA Firm Registration
APPLICATION CHECKLIST
NOTE: ONLY COMPLETE PACKAGES WILL BE ACCEPTED BY NASBA LICENSING SERVICES.
FAILURE TO INCLUDE ALL NECESSARY DOCUMENTATION WILL RESULT IN THE RETURN OF
YOUR APPLICATION. PLEASE INCLUDE THIS CHECKLIST WITH YOUR COMPLETE APPLICATION
PACKET.
Application Form
Consent Form (If there is more than one partner, member, shareholder, etc., only one consent form is required.)
FEE - $240 certified check, money order or credit card made payable to NASBA Licensing Services.
Mail application to:
P.O. Box 198589
Nashville, TN 37219
Toll Free : 866.350.0017
615.880.4200
www.nasbatools.com
P.O. Box 198589
Nashville, TN 37219
GEORGIA
Application for CPA Firm Registration
Firm Name
Type of Entity
Partnership
Corporation
Other
FEI Number
Telephone Number
E-Mail Address
Physical Address:
Street
City
State
Zip Code
List names of partners, members, officers or shareholders personally engaged in the practice of public
accountancy in Georgia (non-CPA owners are not required to hold a license-Board Rule 20-7-.02)
Name
Name of non-CPA owners in firm
% of ownership
Active Inactive
% of ownership
License #
Active
State
Inactive
1. In addition to the owner, does the firm have one or more employees who hold live permits to practice
under standards of equivalance in Georgia?
Yes
No
2. U.S. Citizen:
Yes
No *If non-U.S. Citizen submit supporting documentation
3. Date firm commenced practicing in Georgia under firm name listed
(If application not filed within ninety (90) days after commencing practice, firm must submit a late fee
of $250.00 in addition to appropriate registration fee above.)
4. Has the firm ever held firm registration in Georgia?
Are any of these firms currently in business?
Are you still associated with any of the firms?
If so, list firm name & license number.
Yes
Yes
No
No
5. Have any of the owners/licensees had a license revoked, suspended, or otherwise sanctioned by any
board or agency in Georgia or any other state?
Yes
No
(If yes, attach order)
6. Have any of the owners/licensees been denied issuance of or, pursuant to disciplinary proceeding,
refused renewal of any license by any board or agency in Georgia or any other state?
(If yes, attach copy of order)
Yes
No
7. Have any of the Partners, Members, Officers, or Shareholders of the firm ever been convicted of a
felony or misdemeanor (other than minor traffic violation) or entered a plea of guilty, nolo contendere,
or a plea under the "First Offender Act"? DUI and DWI are not minor traffic offenses.
(If yes, attach copy of conviction or plea.)
Yes
No
8. Is this firm within compliance to the Georgia Peer Review requirements?
Yes
Address
Name of Resident Manager
No
Georgia Cert. #
Office #1
Office #2
Office #3
Office #4
**Resident Manager is only required if you have offices inside the state of Georgia.
Firm Name
County of
State of
I,
, being duly sworn upon oath, depose and say
that the answers to the foregoing questions and statements made in the above application
for registration are true and correct. I further state that I have read and understand the
current rules and regulations of the Georgia State Board of Accountancy, and that I will
advise the Board Office of any changes in this registration within thirty (30) days of such
change.
Signature
Subscribed and sworn to before me this
day of
,
.
Notary Public
Seal
My commission expires
P.O. Box 198589
Nashville, TN 37219
Consent Form
I authorize the Georgia State Board of Accountancy to conduct a background investigation of me
to determine my suitability for licensure and/or registration. I give my consent for full and
complete disclosure of all records and information concerning myself to the Board, their authorized
representatives, or any other persons deemed necessary by the Board in determining my suitability,
whether such records and information are of a public, private, or confidential nature, to include
criminal history records. This authorization will remain in effect for the duration of my active
licensure status with this state or until cancelled by me in writing.
Applicant's Full Name
Physical Address (PO box not accepted)
Mailing Address
Race
Sex
Date of Birth
Social Security Number
Place of Birth (City/State)
Aliases or Maiden Name
Signature of Applicant
Date
Credit Card Payment Form
Applicant Name:
Fees are non-refundable and non-transferable
Authorized Payment Amount:
Please Check One:
Exam ($170)
Transfer/Reciprocity ($320)
Firm ($240)
Pre-Evaluation ($50)
Late Fee ($250)
Visa
MasterCard
Card Number:
Expiration Date:
Print Name as it appears on account:
Authorized Signature:
Return this payment form with Application Package.
Note: This document will be shredded after it has been processed