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SIGN ONLY THE SECTION THAT APPLIES TO YOU <br /> If RENEWING AS ACTIVE, SIGN: HERE <br /> I certify to the truth and accuracy of all statements, answers -and representations made in this <br /> renewal application and CPE report, including all supplementary statements. I certify further <br /> that-.all: CPE programs described herein contribute directly to my professional competence as <br /> a certified public accountant or licensed ublic accountant. <br /> p <br /> ~ Si nature <br /> g _ Date Permit # <br /> i <br /> ~ IF RENEWING AS INACTIVE, SIGN HERE <br /> I hereby apply for inactive status under oRS 673.220 and oAR 801-010-0120. I certify that: <br /> (1) I hold a permit issued under oRS 673.150 or 673.100 which is not revoked or <br /> suspended; _ <br /> (2) I do not perform public accounting services as defined in oAR 801-005-0010; <br /> (3)1 will use the word "inactive" or "retired" if I use the CPA or PA designation, <br /> OAR 801-010-0120; and <br /> (4) I will not perform public accotantin services~until m <br /> 9 y .permit is reinstated to active <br /> status by the Board pursuant to OAR 801-010-0130 and OAR 801-040-0090. <br /> Signature Date Permit # <br /> If you have held an active license for five years and you are interested in serving on <br /> 1 one of the Board's standing committees, ~ the box: ~ ~ ~ ~ j <br /> Renewals must be postmarked by June 30. If the postmark ~is dated after June 30, a <br /> late fee will be assessed. The postmark must be provided by a USPS or other ~ <br /> commercial mall delivery. Mailing dates stamped by a 'private postage meter will <br /> not be accepted to establish timely. renewal. <br /> I~ circle payment(s) sub PAYMENT INFORMATION <br /> --ctpe S;fatus: 15 < , . Oregon Board ofi-.Accoeantarsc <br /> Use this address if paying b Unit 05 <br /> Active Late Fee: $ 50 by check or money order: PO Box 4395 <br /> Portland OR 97208-4395 <br /> Inactive Status:. $ 50 <br /> C ~ t Cs~, <br /> Inactive Late Fee: ~ <br /> $ 35 Use this address if paying 32113 Pringle Rd SE #110 ~ ~ <br /> by Visa or MasterCard: Salem OR 97302 ~ <br /> Muni. Auditor Fee: $100 <br /> ~j <br /> <br /> . Account Number Exp Date: j' <br /> 'I <br /> Address: _ _ _ _ 3-Digit Code ~ ~ <br /> Amount Authorized Print Name <br /> Signature- Date <br /> ?008 Active Renewal Oregon Board of Accountancy Page 4 of 4 <br /> _ _ _ _ _ _ <br /> <br />