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Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov 2022 US VIRGIN ISLANDS BOARD OF PUBLIC ACCOUNTANCY APPLICATION FOR EXAMINATION and INITIAL LICENSURE All supporting documentation submitted prior to a complete application submittal will only remain on file for one year from the date received. ___ UAA Exam ___Reciprocity and USVI Local CPA Exam ___ Initial Licensure and USVI Regulation (Local) Exam I hereby apply for a certification of Certified Public Accountancy, under the laws of the Virgin Islands of the United States, and I agree to abide by the decisions of the Virgin Islands Board of Public Accountancy as to this application. I tender herewith $150.00 non-refundable application fee, in payment of the application. I agree to conform to the rules and regulations of the Board, and if accepted, to be governed by laws and rules of the Board. An application will not be considered filed until the application fee and examination fee required by these Rules and all required supporting documents have been received, including proof of identity as determined by the Board and specified on the application form, official transcripts and proof that the Candidate has satisfied the education requirement. A Candidate who fails to appear for the examination shall forfeit all fees charged for both the application and the examination. Part I 1. Legal Name First Middle Last 2. Physical Address 3. Mailing Address 4. Business Name 5. Business Address 6. Email Address: 7. Business Tel ( ___ ) _______________ Mobile( ___) _______________________ 8. Birth Date ___________ 9. Birthplace _______________________ 10. Social Security Number: 11. Virgin Islands Resident ( ) yes ( ) no If yes, how long? __________ 12. Previous Physical Address 13. Present Business Activity 14. Have you ever been convicted of a felony? ___ yes ___ no. If yes, please explain: For DLCA use only: Date rec’d: _________ Date filed: _________ Date transmitted to Board: _________ Attach (3) 2x2 photos of Applicant here Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov (2022) 15. If applying for reciprocity, list current professional registrations: IF YES, LIST CURRENT PROFESSIONAL REGISTRATIONS: State/Country Registration or License # Title of License Expiration Date Good Standing 16. Has your license ever been revoked? ( ) yes ( ) no If yes, please explain: 17. Have you ever been censured for unprofessional conduct? ( ) yes ( ) no If yes, please explain: 18. Have you ever taken the Uniform C.P.A. Examination? ( ) yes ( )no IF YES, PLEASE LIST: Type of Exam Place Date Result 19. Have you taken any other accounting examinations? ( ) yes ( ) no IF YES, PLEASE LIST: Type of Exam Place Date Result Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov (2022) 20. List present or past membership in any accounting society: ACCOUNTING SOCIETY MEMBERSHIP LEVEL 21. PROFESSIONAL & CHARACTER REFERENCES List and submit three (3) professional references from practicing Certified Public Accountant, (note that at least, one must be from the US Virgin Islands) and two (2) character references. Please submit copies of current registrations for each practicing CPA used as a reference. Name Address Telephone Number 1. 2. 3. 4. 5. Part II. FOR NEW APPLICANTS ONLY The CPA Board will not consider any application unless it contains full details of every employment or other occupation (whether related to accounting or not) prior to date of application. The name and address of every school and employer must be given and be accompanied by the dates of attendance or employment. In the case of practice on the applicants own account, there must be evidence supporting the statements made. Applications lacking the complete information required will not be considered by the Board. 22. Educational Requirements: 150 credit hours of college education to include an accounting concentration or equivalent is required for UAA examination and licensure. An official sealed transcript must be sent from the institution directly to the Board. Applicant must have earned a Baccalaureate or Graduate degree from an accredited university; obtained at a minimum 24 semester hours of accounting courses including auditing & attestation, financial accounting and reporting, cost and management accounting, and taxation; in addition, 24 semester hours of business courses. The VI Code and Board Rules and Regulations are available on DLCA’s website at http://www.dlca.vi.gov/boardcertifications/steps/cparequirements/cpalist.htm School Address Date of Attendance Degree Earned Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov (2022) 23. EMPLOYMENT REQUIREMENT THIS FORM MUST BE SUBMITTED BY THE VERIFIER. APPLICANTS SUBMITTAL OF THIS INFORMATION WILL NOT BE ACCEPTED. VERIFIER’S RESPONSIBILITIES: You have personally verified the work performed by the candidate. You certify that your CPA license was current throughout the entire duration of the candidate’s experience. You either employed the candidate or both you and the candidate were employed by the same firm and the experience listed is appropriate for the applicable categories. The verifying licensed professional must complete this section and return directly to the VI State Board of Accountancy at the above listed address. Employment shall consist of full or part time employment that extends over a period of no less than a year and no more than three years and includes no fewer than 2,000 hours of performance of services described in section 3.2c of the Rules. Please list the hours performed by the candidate in each category and give a FULL explanation of the work done in each category. Please attach narrative if additional space is required and list the category where the hours were obtained. APPLICANT NAME: __________________________________________________________ VERIFIER NAME/TITLE: ______________________________________________________ LICENSED VERIFIER PROFESSIONAL INFORMATION: BUSINESS NAME AT TIME OF VERIFICATION: _________________________________ BUSINESS ADDRESS: _________________________________________________________ CONTACT NUMBER (S): ___________________________________________________ TYPE OF INDUSTRY:  - GOVERNMENT  - ACADEMIA  - INDUSTRY (not an accounting firm)  - PUBLIC PRACTICE (accounting firm)  - OTHER (specify below) ______________________________________________________________________________ _____________________________________________________________________________ CANDIDATE’S EXPERIENCE UNDER MY VERIFICATION WAS FROM: NOTE: DATE CANNOT GO PAST DATE THAT CERTIFICATION APPLICATION RECEIVED BY BOARD. ___/___/_____ TO ___/___/_____ (USE COMPLETE DATES) MM/DD/YYYY MM/DD/YYYY INTERNSHIP DATES, IF APPLICABLE: INTERNSHIPS CANNOT BE COUNTED IF ON COLLEGE TRANSCRIPTS FOR CREDIT ___/___/_____ TO ___/___/_____ (USE COMPLETE DATES) MM/DD/YYYY MM/DD/YYYY Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov (2022) EMPLOYMENT REQUIREMENT (#23 Verifier portion continued) THIS FORM MUST BE SUBMITTED BY THE VERIFIER. APPLICANTS SUBMITTAL OF THIS INFORMATION WILL NOT BE ACCEPTED. EXPERIENCE WAS OBTAINED IN: Certification I certify under the penalty of perjury that my verification of the candidate’s experience is true and correct and that they have obtained the experience as indicated and that I was currently licensed to practice as a CPA during the period of verification. I verify that this application is in the original format as supplied by the Department and has not been altered or otherwise modified in any way. I verify that the statements in this application are true and correct to the best of my knowledge, information, and belief. I understand that false statements may result in the suspension, revocation or denial of my license, certificate, permit or registration. ______________________________________________ Signature of Verifier - DO NOT PRINT _______________________________ ______________ _______________ Printed Name of Verifier License Number State of Licensure ___________________________ ______________________ Expiration Date of License Date Signed - must be within 30 days of receipt. VERIFIER MUST BE ACTIVELY LICENSED THROUGHOUT THE WHOLE PERIOD OF VERIFICATION. Remarks (State here any other facts which you feel are important to this application): Category No. of Hours Job Title Duties (be specific) Accounting Attestation Management Advisory Financial Advisory Tax Consulting Grand Total Hours Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov (2022) AFFIDAVIT (Must be completed by all applicants) State of Territory of Country I,_____________________________, being duly sworn, depose and say that I am the person who executed the foregoing instrument; that I have read the same and know the contents thereof; that the matters stated therein are true to my knowledge; that I have not suppressed any information that might affect this application; and that I have read and understand this affidavit. Applicant's Signature Sworn and subscribed before me this _______day of ____________________, 20 ____. SEAL _______________________________ Notary Public My Commission expires on _________ Do not write below this line: Board Disposition Application Approved: ( _____ ) YES ( _____) NO Signature, Chairman of the Board Date Member Member Member Member Member Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center Administrative Complex Property & Procurement Building 3000 Estate Golden Rock, Suite 9 “The Battery” 8201 Subbase, Suite 1 St. Croix, VI 00820-4311 St. John, VI 00830 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 “Serving Businesses and Assisting, Educating, & Protecting Consumers” www.dlca.vi.gov (2022) US Virgin Islands Board of Public Accountancy Uniform and VI Regulation “Local” Examination Registration Form Date: __________________ Name: ____________________________ SS#: _______________________ Mailing Address: ______________________________________________________ Physical Address: ________________________________________________ Business Number: _________________ Home Number: ______________ Fax Number: _____________________ E-mail: _____________________ Mother's Maiden Name: _________________________________ Date of last exam section passed: ________ Section Name________________ If applying for reciprocity, what state(s) are you currently licensed in: _____________________________________________ Please indicate which section(s) you will be taking by placing an (X) on the line. Be sure to enclose the proper fees for each section. Payment by check or money order should be made payable to the Government of the Virgin Islands. ___________ Auditing and Attestation $360.00 ___________ Financial Accounting & Reporting $360.00 ___________ Regulation $360.00 ___________ Business Environment & Concepts $360.00 ___________ VI Regulation (Local) Exam (Initial) $200.00 ___________ VI Regulation (Local) Exam (Retake) $200.00 ________________________________________________ Signature