I, (name as you want it to
appear on WICPA certificate), hereby apply to be admitted as a member of the
Wisconsin Institute of Certified Public Accountants. I agree to abide by the decisions of
the Board of Directors as to this application.
Please state maiden name if different than
above
Current status:
Employed
Unemployed
Student
Other (explain):
Residence information:
Employer information:
If you are an applicant practicing on your own, please list date you founded your firm
and enclose a letterhead marked "sample." List a WICPA member or other person
who is qualified to serve as a reference source for this information.
Type of Business:
Type of business (check only one):
Type of industry (check only one):
CPA Exam/Certificates:
Date CPA Examination Passed:
mm/dd/yy
state
If you passed the CPA exam in a state other than Wisconsin and have not received your CPA
certificate, please include a photocopy of your notification of passage.
Do you hold a CPA certificate?
Yes No
If you do not hold a CPA certificate from Wisconsin but do
hold one from another state, please include a photocopy of your CPA certificate.
If you hold an in-state certificate, please fill out the information below.
Date issued:
mm/dd/yy
Certificate number:
Are you currently licensed to practice public accounting in Wisconsin?
Yes No
Has any CPA certificate issued to you ever been suspended or revoked?
Yes No
(If yes, submit details.)
General Information:
Address preferred for institute mailings:
Citizen of:
Have you ever been convicted by any court or
other body of a felony?
Yes No
If yes, submit details.
Have you previously been a member of WICPA? If yes, submit details.
Yes No
If yes, submit details.
Are you a member of the American Institute of CPAs?
Yes No
Are you a resident member of another state society?
Yes No
State:
Employment History:
Employer/firm, address, and position:
Education:
Are you a past WICPA scholarship recipient?
Yes No
If yes, date scholarship received :
mm/dd/yy
Which free gift would you like to receive
(click here for details)?
WICPA Member
Endorsement
Endorsed and recommended for membership by a member of the Wisconsin Institute of
Certified Public Accountants:
Endorsing Member:
Endorsing Member's Employer:
I hereby certify that the information I have provided is correct to the best of my
knowledge and belief. I further certify that I have not suppressed any information which
might have a bearing on this application; and upon being elected a member, I agree to
abide by the Constitution, By-Laws and Rules of Professional Conduct of the Wisconsin
Institute of Certified Public Accountants.
I hereby agree that in case of my withdrawal from or the termination of my membership,
and upon demand of the secretary, I will at such time surrender to the Institute my
certificate of membership in the WICPA. I understand the information on this application
may be subject to verification.
Name:
Date:
mm/dd/yy
Please submit $30 payment covering the
application fee with the understanding you will receive a bill for your annual dues once
elected to membership: