State of Maryland Department of Labor, Licensing and Regulation
Maryland State Board Of Public Accountancy
500 N. Calvert St., Room 308
Baltimore, Maryland 21202-3651
(410) 230-6322 (Baltimore area),    (888) 218-5925 (Toll Free)

Verification of Licensure Form For Reciprocal Initial Application



I. Candidate must complete this section (please type):

Name
Address
City   , State   Zip Code
Daytime Telephone No.
Email Address


I,   , am applying for a license by reciprocity to the State of Maryland, based upon my License number _
Date Issued: _
By the State of _ .


_
Signature


Note to applicants: Upon completion of Section I, please forward this form to the state board from which you obtained your original license. Include a postage paid, addressed envelope for return to the Maryland Board.





II. THIS SECTION MUST BE COMPLETED BY THE STATE BOARD FROM WHICH YOU OBTAINED THE ORIGINAL LICENSURE (please circle the appropriate answer).


  1. Is the applicant's license in good standing? [ Yes ] [ No ]

  2. Are the License number and date of issue correct? [ Yes ] [ No ]

  3. Did the applicant obtain their CPA certificate by the uniform examintaion? [ Yes ] [ No ]

  4. If the license was not obtained by the uniform written examination, state how it was obtained:
    _ _

    If the license was obtained after passing the AICPA Uniform Examination, please complete the following:

    Date (Month/Year) Grades Received
    Auditing Law Theory Practice
    _ _
    _ _
    _ _



  5. Did the applicant complete the Ethics Examination? [ Yes ] [ No ]
    If yes, indicate date: _






Board Seal Signature _

Title _

Date _