THE PUBLIC ACCOUNTANTS LICENSING BOARD INDIVIDUAL APPLICATION FOR LICENSURE 2013

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TELEPHONE (office)____________________________(home)________________________________________ FAX_____________________________________________________________________________________ ___ E-MAIL ADDRESS____________________________________________________________________________

I HEREBY APPLY FOR LICENSURE AS A PUBLIC ACCOUNTANT PURSUANT TO THE PUBLIC ACCOUNTANTS ACT (NL) AND I ENCLOSE THE FOLLOWING DOCUMENTS WHICH I ACKNOWLEDGE ARE REQUIRED TO BE SUBMITTED TO BE CONSIDERED FOR PALB LICENSURE: 1. THIS COMPLETED ORIGINAL FORM 2. CERTIFICATE OF INSURANCE FROM INSURANCE COMPANY CONFIRMING ANNUAL PROFESSIONAL LIABILITY INSURANCE COVERAGE FOR 2013 OF A MINIMUM OF $1M PER INDIVIDUAL CLAIM AND $2M AGGREGATE CLAIMS PER ANNUM 3. CHEQUE OR MONEY ORDER ($120 annual licensing fee for 2013. A $200 new application processing fee will be an additional fee charged to both new applicants and renewal applications received after January 31st.) 4. CERTIFICATION FROM AN AUTHORIZED REPRESENTATIVE OF YOUR ACCOUNTING BODY THAT YOU ARE BOTH A MEMBER IN GOOD STANDING AND MEET THE REQUIREMENTS OF THAT ACCOUNTING BODY TO PRACTICE PUBLIC ACCOUNTING. Dated at_______________________________________ in the Province of ____________________________ this________________ day of __________________________, 201______.

Signature DOCUMENTS MUST BE SUBMITTED TO:

Dr. Dennis Hanlon, Registrar Public Accountants Licensing Board Faculty of Business Administration Memorial University of Newfoundland St. Johns, NL A1B 3X5

Notes:

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The licensing fee for 2013 is $120 and should be forwarded to the Board by December 31, 2012, but in no case later than January 31, 2013. Post-dated cheques are not acceptable. Your cheque or money order should be made payable to the Public Accountants Licensing Board. Please ensure all documentation referred to above is included. Please notify the Board of any changes in your address. Please do not copy this form for potential new licensees; they should contact the Board directly.