ATTENTION Please Note: The attached form is only the application. There is a more complete CPA information package that is being developed to be included with the application. Please contact the DCRA Business Center for the information package. They may be reached at 202-442-8959. American LegalNet, Inc. www.USCourtForms.com DEPARTMENT OF CONSUMER AND REGULATORY AFFAIRS OCCUPATIONAL AND PROFESSIONAL LICENSING ADMINISTRATION P.O. BOX 37200 WASHINGTON, D.C. 20013-7200 OPLA-24 (Rev. 10/85) APPLICATION FOR D.C. LICENSE FOR OFFICE USE ONLY AMOUNT OF FEE BASIS OF LICENSURE DATE PAID date CATEGORY CODE EXAMINATION test score APPLICATION EXAMINATION LICENSE APPLICATION NO. state RECIPROCITY $ ENDORSEMENT BOARD APPROVED AUDIT/LICENSE NO. COMPLAINTS Fll.ED Yes No MIS ONLY state LICENSE PERIOD STREET CODE OTHER from to QUADRANT CODE TO BE COMPLETED BY APPLICANT (PLEASE READ INSTRUCTIONS FIRST) (PRINT IN INK OR TYPE) Examination 11. DATE OF APPLICATION 6. BASIS OF Individual 5. 1. TYPE OF LICENSE APPLICATION Partnership Corporation 2. NAME OF APPLICANT (Last, First, MI) 7. SEX Re-examination Reciprocity Endorsement Other ( specify) Male Female 3. RESIDENCE ADDRESS (Street, City, State, Zip Code) * 12. SOCIAL SECURITY NUMBER 13. DATE OF BIRTH 14. PLACE OF BIRTH TRADE NAME 8. OR 15. TELEPHONE NUMBER Residence Business EMPLOYER NAME 4. BILLING ADDRESS (Street, City, State, Zip Code) 9. BUSINESS ADDRESS ( Street, City, State, Zip Code ) 16. CERTIFICATE OF OCCUPANCY (if applicable) NUMBER 10. D.C. WARD 17. SCHOOL ATTENDED (name, city, state or foreign country) 18. Total No. of hours 22. Have you ever been arrested or convicted of a crime? (omit traffic violations) Yes No If yes, attach explanation. 24. Are you now or have you ever been licensed in D.C. or any other jurisdiction? If yes, give the following information on original liceuxure: License No. License Date 19 Date of Graduation 20. Type of Degree/Certificate 23. Are you currently bonded? Yes 21. Year Degree Received No If yes, give expiration date No Yes Jurisdiction Issue Basis 25. Have you ever surrendered license or has license been denied, revoked or suspended by any jurisdicton? If yes, attach explanation. Yes No 26. AFFIDAVIT OF APPLICANT , being duly sworn, deposes and says: That the information given in this application, including all writings and exhibits attached hereto, is true and complete. Signature of Applicant District of Columbia ss. Subscribed and sworn to before me this appeared before me. day of , 20 by the affiant, who personally ( SEAL ) My Commission expires Notary Public 1. All applicants must complete applicable portions of supplemental page and submit all supporting doucments required. 2. Fee must accompany application. All fees are earned when paid and cannot be transferred or refunded. 3. Make checks payable to D.C. TREASURER. A charge of $50.00 will be imposed for dishonored checks. (Public Law 89-208) 4. False or misleading statements will be cause for rejection of application or revocation of license. 5. If more space is needed to fully answer questions, attach additional page(s). *Under the authority of Public Law 93-579, Section 7(b), the Department of Consumer and Regulatory Affairs requests your Social Security Number to assist in the administration of D.C. tax laws. Disclosure is not required as a part of the licensing process and will not be made available to the public. American LegalNet, Inc. www.USCourtForms.com