Form DBPR CPA12 "Authorization for Transfer of Examination and/or Licensure Information Request" - Florida

What Is Form DBPR CPA12?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2021;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DBPR CPA12 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR CPA12 "Authorization for Transfer of Examination and/or Licensure Information Request" - Florida

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Page 1 of 1
State of Florida
Department of Business and Professional Regulation
Florida Board of Accountancy
Authorization for Transfer of Examination and/or Licensure Information Request
Form # DBPR CPA 12
If you have any questions or need assistance in completing this request, please contact the Department of Business and
Professional Regulation, Customer Contact Center at (850) 487-1395.
Instructions:
Complete this form to request the Florida Board of Accountancy to send verification of
examination and licensure information to another state's board.
Please be advised there is a processing fee of
$50 for each request.
TO BE COMPLETED BY THE APPLICANT (Please type or print legibly):
It is the responsibility of the applicant to provide accurate information. The Florida Board of Accountancy is not liable for
data not received by another state’s board in the event that the information provided by the applicant is incorrect.
APPLICANT LEGAL NAME
LAST
FIRST
MIDDLE
MAIDEN
CURRENT MAILING ADDRESS
STREET
APARTMENT/SUITE #
CITY
STATE/TERRITORY
ZIP/POSTAL CODE
CONTACT INFORMATION
PRIMARY TELEPHONE
PRIMARY EMAIL ADDRESS
PERSONAL IDENTIFICATION INFORMATION
*SOCIAL SECURITY NUMBER
DATE OF BIRTH
LICENSE NUMBER (If Applicable)
*Under the Federal Privacy Act, disclosure of Soc. Sec. Numbers is voluntary unless specifically required by Federal status. In this instance, social
security numbers are mandatory pursuant to Title 42 United States Code, Section 653 & 654; and sections 445.203(9), 409.2577, &409.2598, Florida
Statutes. Social Security numbers are used to allow efficient screening of applicants & licensees by a Title IV-D child support agency to assure
compliance with child support obligations. Social Security numbers must also be recorded on all professional & occupational license applications & will be
used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104
Pub.L.193, Sec 317.
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby request and authorize the Florida Board of Accountancy to provide any and all pertinent information to the Board
of Accountancy in the state of _______________________________________
to complete an application filed with that
agency. I agree that the state Board may confirm the grades issued to me by the Advisory Grading Services of the
American Institute of Certified Public Accountants.
________________________________________________
________________________________________
Applicant Signature
Date Signed
SUBMIT FORM TO: Department of Business and Professional Regulation, 2601 Blair Stone Road, Tallahassee, FL 32399.
For more information regarding the requirements, please refer to Chapter 61H1, Florida Administrative Code and Chapter
473, Florida Statutes. Links are located on the board’s website under
Statutes and
Rules.
DBPR CPA 12 Authorization for Transfer of
Examination and/or Licensure Information Request
Eff. Date: June 2021
Incorporated by Rule: 61-35.003, F.A.C.
Page 1 of 1
State of Florida
Department of Business and Professional Regulation
Florida Board of Accountancy
Authorization for Transfer of Examination and/or Licensure Information Request
Form # DBPR CPA 12
If you have any questions or need assistance in completing this request, please contact the Department of Business and
Professional Regulation, Customer Contact Center at (850) 487-1395.
Instructions:
Complete this form to request the Florida Board of Accountancy to send verification of
examination and licensure information to another state's board.
Please be advised there is a processing fee of
$50 for each request.
TO BE COMPLETED BY THE APPLICANT (Please type or print legibly):
It is the responsibility of the applicant to provide accurate information. The Florida Board of Accountancy is not liable for
data not received by another state’s board in the event that the information provided by the applicant is incorrect.
APPLICANT LEGAL NAME
LAST
FIRST
MIDDLE
MAIDEN
CURRENT MAILING ADDRESS
STREET
APARTMENT/SUITE #
CITY
STATE/TERRITORY
ZIP/POSTAL CODE
CONTACT INFORMATION
PRIMARY TELEPHONE
PRIMARY EMAIL ADDRESS
PERSONAL IDENTIFICATION INFORMATION
*SOCIAL SECURITY NUMBER
DATE OF BIRTH
LICENSE NUMBER (If Applicable)
*Under the Federal Privacy Act, disclosure of Soc. Sec. Numbers is voluntary unless specifically required by Federal status. In this instance, social
security numbers are mandatory pursuant to Title 42 United States Code, Section 653 & 654; and sections 445.203(9), 409.2577, &409.2598, Florida
Statutes. Social Security numbers are used to allow efficient screening of applicants & licensees by a Title IV-D child support agency to assure
compliance with child support obligations. Social Security numbers must also be recorded on all professional & occupational license applications & will be
used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104
Pub.L.193, Sec 317.
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby request and authorize the Florida Board of Accountancy to provide any and all pertinent information to the Board
of Accountancy in the state of _______________________________________
to complete an application filed with that
agency. I agree that the state Board may confirm the grades issued to me by the Advisory Grading Services of the
American Institute of Certified Public Accountants.
________________________________________________
________________________________________
Applicant Signature
Date Signed
SUBMIT FORM TO: Department of Business and Professional Regulation, 2601 Blair Stone Road, Tallahassee, FL 32399.
For more information regarding the requirements, please refer to Chapter 61H1, Florida Administrative Code and Chapter
473, Florida Statutes. Links are located on the board’s website under
Statutes and
Rules.
DBPR CPA 12 Authorization for Transfer of
Examination and/or Licensure Information Request
Eff. Date: June 2021
Incorporated by Rule: 61-35.003, F.A.C.