Instruction Sheet for Authorization for Interstate Exchange of Information Form

If you passed the exam in a state that NASBA processes the exam for, you may obtain verificationof your CPA exam scores by submitting an application online at https://www.nasbastore.org.
If you passed the exam in a state that NASBA does not process score transfers for, forward to theboard from which you passed the CPA Examination.
Note: A fee might be required to accompany such a request. Please check with your state board directly.

Upon receipt of completed form, upload into your online application.
RECIPROCAL APPLICANTS ONLY:
If you are applying as a reciprocal applicant and are licensed in a state that provides an online license
verification, rather than submit this form to the state board you are licensed in, you may print off yourlicense verification from the board's website and upload it into the application. The online license
verification must include your name, license number, issue date, and expiration date of your CPA license.
If this information is not provided, this form must be submitted to the state board you are licensed forcompletion. Copies of wallet cards and wall certificates are NOT acceptable.

P.O. Box 198589
Nashville, TN 37219

Authorization for Interstate Exchange of Information Form
State Boards: The applicant below has authorized you to provide any and all pertinent information listed in this form
to NASBA Licensing Services, a division of the National Association of State Boards of Accountancy. Please return theform in a sealed envelope directly to the applicant. Do not send to NASBA Licensing Services

First Name

Last Name

Middle Name

Maiden/Other Name

Street or P.O. BoxCityStateDaytime TelephoneZip Code

Date of BirthCertificate Number (if applicable)
I hereby request and authorize theBoard of Accountancy to provide any
and all pertinent information requested in this form to CPA Examination Services. I agree that CPA
Examination Services may confirm the grades issued to me by the Advisory Grading Service of theAmerican Institute of Certified Public Accountants.

DateSignatureState Board use only:
Date ofExamination

Date applicant initially sat for the exam:
Candidate ID #Audit

LPR(Business Law)

FARE(Theory)

1. Was the applicant ever denied admission to the Exam?

Yes

2. If the applicant has not completed the CPA Exam, arethere any restrictions preventing him/her from sitting inyour state?

Yes

3. If the applicant has not passed all parts of the CPA Exam,indicate above the expiration date of those parts that havebeen passed and for which credit has been given.

ARE(Practice)

No (If yes, please explain on following page.)

No (If yes, please explain on following page.)1. The applicant was granted an original/reciprocal (circle one) CPA Certificate number
issuedwhich is in good standing unless noted below.
2. The applicant has completed an Ethics ExaminationThe exam was prepared and graded byBoard

Yes
NoAICPAScore:

License/Permit to Practice Public Accounting
3.
4.
5.
6.

Yes
Yes
Yes
Yes

NoNoNoNo

This state is a two-tier state.
The license/permit from this board is in good standing and expires
The applicant is currently licensed to engage in the practice of public accounting.
Has there ever been any disciplinary action instituted against the applicant?
(If yes, explain below.)

7. If the applicant does not hold a license/permit from your board, please indicate the requirements to be metfor issuance or reinstatement:
License/Permit not required:
Pay appropriate fees/or post bond:Complete acceptable accounting/auditing experience:
Complete continuing professional education requirements:
Other:
Additional Information:

Exceptions noted/explanations:Board Seal

Board/Agency
Official Signature
TitleDate