Nomination Form for Passing Score Panels

1) NAME:

First Name
Middle Initial
Last Name

2) GENDER:

Male

Female

3) ETHNICITY:

American Indian or Alaska NativeAsianBlack or African-AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhitePrefer Not To Provide

4) FIRM:

5) JOB TITLE:

6) FIRM ADDRESS:

7) SUITE NUMBER:

8) CITY:

9) STATE:

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareD.C.FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

10) ZIP CODE:

11) TELEPHONE:

12) FAX:

13) EMAIL ADDRESS:

14) YEAR OF INITIAL LICENSURE AS A CPA:

15) NUMBER OF YEARS IN ACCOUNTING PRACTICE:

16) STATES IN WHICH YOU ARE LICENSED AS A CPA: (Choose all that apply)

Alabama   Alaska   Arizona   Arkansas   California   Colorado   Connecticut   Delaware   D.C.   Florida   Georgia   Hawaii   Idaho   Illinois   Indiana   Iowa   Kansas   Kentucky   Louisiana   Maine   Maryland   Massachusetts   Michigan   Minnesota   Mississippi   Missouri   Montana   Nebraska   Nevada   New Hampshire   New Jersey   New Mexico   New York   North Carolina   North Dakota   Ohio   Oklahoma   Oregon   Pennsylvania   Rhode Island   South Carolina   South Dakota   Tennessee   Texas   Utah   Vermont   Virginia   Washington   West Virginia   Wisconsin   Wyoming

17) STATES IN WHICH YOU HAVE MEMBERSHIPS IN CPA SOCIETIES: (Choose all that apply)

Alabama   Alaska   Arizona   Arkansas   California   Colorado   Connecticut   Delaware   D.C.   Florida   Georgia   Hawaii   Idaho   Illinois   Indiana   Iowa   Kansas   Kentucky   Louisiana   Maine   Maryland   Massachusetts   Michigan   Minnesota   Mississippi   Missouri   Montana   Nebraska   Nevada   New Hampshire   New Jersey   New Mexico   New York   North Carolina   North Dakota   Ohio   Oklahoma   Oregon   Pennsylvania   Rhode Island   South Carolina   South Dakota   Tennessee   Texas   Utah   Vermont   Virginia   Washington   West Virginia   Wisconsin   Wyoming

18) STATES IN WHICH YOU HAVE SERVED ON A STATE BOARD OF ACCOUNTANCY: (Choose all that apply)

Alabama   Alaska   Arizona   Arkansas   California   Colorado   Connecticut   Delaware   D.C.   Florida   Georgia   Hawaii   Idaho   Illinois   Indiana   Iowa   Kansas   Kentucky   Louisiana   Maine   Maryland   Massachusetts   Michigan   Minnesota   Mississippi   Missouri   Montana   Nebraska   Nevada   New Hampshire   New Jersey   New Mexico   New York   North Carolina   North Dakota   Ohio   Oklahoma   Oregon   Pennsylvania   Rhode Island   South Carolina   South Dakota   Tennessee   Texas   Utah   Vermont   Virginia   Washington   West Virginia   Wisconsin   Wyoming

19) WHAT IS YOUR PRIMARY JOB RESPONSIBILITY?

20) During the last three years, what percentage of your professional time has been spent on the following?

	None	1-25%	26-50%	51-75%	76-100%
Auditing	Auditing None	Auditing 1-25%	Auditing 26-50%	Auditing 51-75%	Auditing 76-100%
Review	Review None	Review 1-25%	Review 26-50%	Review 51-75%	Review 76-100%
Compilation	Compilation None	Compilation 1-25%	Compilation 26-50%	Compilation 51-75%	Compilation 76-100%
Taxation - Individual	Taxation - Individual None	Taxation - Individual 1-25%	Taxation - Individual 26-50%	Taxation - Individual 51-75%	Taxation - Individual 76-100%
Taxation - Corporate	Taxation - Corporate None	Taxation - Corporate 1-25%	Taxation - Corporate 26-50%	Taxation - Corporate 51-75%	Taxation - Corporate 76-100%
Governmental	Governmental None	Governmental 1-25%	Governmental 26-50%	Governmental 51-75%	Governmental 76-100%
Not For Profit	Not For Profit None	Not For Profit 1-25%	Not For Profit 26-50%	Not For Profit 51-75%	Not For Profit 76-100%
Managerial (Cost) Accounting	Managerial (Cost) Accounting None	Managerial (Cost) Accounting 1-25%	Managerial (Cost) Accounting 26-50%	Managerial (Cost) Accounting 51-75%	Managerial (Cost) Accounting 76-100%
Legal Issues	Legal Issues None	Legal Issues 1-25%	Legal Issues 26-50%	Legal Issues 51-75%	Legal Issues 76-100%
Professional Responsibilities	Professional Responsibilities None	Professional Responsibilities 1-25%	Professional Responsibilities 26-50%	Professional Responsibilities 51-75%	Professional Responsibilities 76-100%
SEC Clients	SEC Clients None	SEC Clients 1-25%	SEC Clients 26-50%	SEC Clients 51-75%	SEC Clients 76-100%

21) During the last 2 years, how many new CPAs (2 years’ experience or less) have you supervised directly? (Check one)

None

1 to 3

4 to 10

11 or more

22) Are you currently affiliated with a CPA review course?

Yes

No

23) How would you describe your firm? (Check one)

Local

Regional

National

Big Four/International