"Application Form for Reinstatement of a Revoked Certificate" - Minnesota

Application Form for Reinstatement of a Revoked Certificate is a legal document that was released by the Minnesota Board of Accountancy - a government authority operating within Minnesota.

Form Details:

  • Released on November 1, 2018;
  • The latest edition currently provided by the Minnesota Board of Accountancy;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Minnesota Board of Accountancy.

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Download "Application Form for Reinstatement of a Revoked Certificate" - Minnesota

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85 East 7th Place, Suite 125, St. Paul, MN 55101-2143
Ph: 651-296-7938 • Fax: 651-282-2644 • boa.state.mn.us
CLEAR
CLEAR
FORM
FORM
APPLICATION FOR REINSTATEMENT OF A REVOKED CERTIFICATE
Military Only u If you are active duty or within 6 months of discharge from active duty, check box:
Certificate #
Name
(First)
(M.I.) (Last)
(Suffix)
Address
Home Phone
City
State
Zip
Work Phone
Provide your employment history for the period since revocation, listing the most recent employer first.
Include a description of the type of services you perform(ed). Use additional sheets as needed.
Employer Name & Address
Dates Employed
Types of Services Performed
Have you ever been suspended, expelled, revoked or otherwise disciplined in
Yes*
No
any manner by any organization related to the practice of public accounting?
Have you ever been convicted of any crime,
Yes*
No
misdemeanor or any other discreditable act?
*
If you answered “Yes” to either statement above, include a statement of explanation on a separate sheet.
Active
Inactive
What was your certificate status prior to revocation?
AFFIDAVIT (read and sign):
I acknowledge that since the date of revocation of my certificate, I have not applied for or been issued a
certificate by the Board. Further, I acknowledge that since revocation of my certificate, I have not engaged in activities requiring an active
certificate. I certify that the information supplied on this application for reinstatement is accurate and that any misrepresentation may be cause
for disciplinary action. In accordance with Minn. Stat. §326A.09 (2018), the undersigned requests reinstatement of the revoked certificate.
Date
Signature
NOTICE OF COLLECTION OF PRIVATE DATA
In accordance with the Minnesota Government Data Practices Act (MN Statute §13.04, Subd. 2), the Board is required to inform you of your rights as they
pertain to private data collected from you on this application for licensure. The data you furnish on the application will be used by the Board to assess your
qualifications for licensure. The collection of your social security number by the Board is required by both federal and state laws. If you fail to provide this
data, the Board may be unable to approve your application or issue your license.
Federal law (42 U.S.C. 666(a)(13)) requires each state to collect social security numbers at the time of application for a professional or occupational
license in order to improve effectiveness of child support enforcement.
Additionally, pursuant to Minnesota Statutes §270C.72, subdivision 4 (2018) the Board must provide the Commissioner of the Minnesota Department
of Revenue a list of all applicants, including name, address and social security number or Individual Tax Identification Number (ITIN), each calendar year
for the purpose of identifying individuals owing delinquent taxes. Pursuant to Minnesota Statutes §13.41, subdivision 2 (2018), all application data, except
name and designated address, are private data until licensure is granted. When licensure is granted, all data, except social security number and non-
designated address, become public record.
The Board will not share your private data with other persons or agencies unless you authorize its release or it is required by law or court order.
Rev 11/18
Authorization to Release Information Form—Page 1 of 1
85 East 7th Place, Suite 125, St. Paul, MN 55101-2143
Ph: 651-296-7938 • Fax: 651-282-2644 • boa.state.mn.us
CLEAR
CLEAR
FORM
FORM
APPLICATION FOR REINSTATEMENT OF A REVOKED CERTIFICATE
Military Only u If you are active duty or within 6 months of discharge from active duty, check box:
Certificate #
Name
(First)
(M.I.) (Last)
(Suffix)
Address
Home Phone
City
State
Zip
Work Phone
Provide your employment history for the period since revocation, listing the most recent employer first.
Include a description of the type of services you perform(ed). Use additional sheets as needed.
Employer Name & Address
Dates Employed
Types of Services Performed
Have you ever been suspended, expelled, revoked or otherwise disciplined in
Yes*
No
any manner by any organization related to the practice of public accounting?
Have you ever been convicted of any crime,
Yes*
No
misdemeanor or any other discreditable act?
*
If you answered “Yes” to either statement above, include a statement of explanation on a separate sheet.
Active
Inactive
What was your certificate status prior to revocation?
AFFIDAVIT (read and sign):
I acknowledge that since the date of revocation of my certificate, I have not applied for or been issued a
certificate by the Board. Further, I acknowledge that since revocation of my certificate, I have not engaged in activities requiring an active
certificate. I certify that the information supplied on this application for reinstatement is accurate and that any misrepresentation may be cause
for disciplinary action. In accordance with Minn. Stat. §326A.09 (2018), the undersigned requests reinstatement of the revoked certificate.
Date
Signature
NOTICE OF COLLECTION OF PRIVATE DATA
In accordance with the Minnesota Government Data Practices Act (MN Statute §13.04, Subd. 2), the Board is required to inform you of your rights as they
pertain to private data collected from you on this application for licensure. The data you furnish on the application will be used by the Board to assess your
qualifications for licensure. The collection of your social security number by the Board is required by both federal and state laws. If you fail to provide this
data, the Board may be unable to approve your application or issue your license.
Federal law (42 U.S.C. 666(a)(13)) requires each state to collect social security numbers at the time of application for a professional or occupational
license in order to improve effectiveness of child support enforcement.
Additionally, pursuant to Minnesota Statutes §270C.72, subdivision 4 (2018) the Board must provide the Commissioner of the Minnesota Department
of Revenue a list of all applicants, including name, address and social security number or Individual Tax Identification Number (ITIN), each calendar year
for the purpose of identifying individuals owing delinquent taxes. Pursuant to Minnesota Statutes §13.41, subdivision 2 (2018), all application data, except
name and designated address, are private data until licensure is granted. When licensure is granted, all data, except social security number and non-
designated address, become public record.
The Board will not share your private data with other persons or agencies unless you authorize its release or it is required by law or court order.
Rev 11/18
Authorization to Release Information Form—Page 1 of 1