Georgia Reinstatement Nursing – Fill Out and Use

APPLICATION FOR REINSTATEMENT OF LICENSE

GEORGIA STATE BOARD OF ACCOUNTANCY

237 Coliseum Drive

Macon, GA 31217

Phone (478) 207-2440

www.sos.georgia.gov/plb/accountancy/

Please read the instructions carefully and be familiar with the laws and rules governing the practice of accountancy in the State of Georgia. Visit the following website for information: www.sos.georgia.gov/plb/accountancy/. Board Rule 20-10-.04 concerning reinstatement of licensure is enclosed within this application.

The Board cannot process incomplete applications. If any item is missing, incomplete or incorrect, your application cannot be reviewed by the Board. Please review the check list below and this application before you submit it to ensure that all information and documentation is complete and correct.

Consent Form for background check. This form must be completed, signed and returned with your application or your complete application will be returned.

Activities Since Last Renewal. Field must be completed. Answers could be: did not need, out of country, sick, etc.

Non-refundable application fee of $150.00 (check or money order) made payable to Georgia State Board of Accountancy

Reason For Failing To Renew. Field must be completed.

Required completed hours of continuing professional education for reinstatement.

See the table below on left for the required number of hours required for reinstatement of license. If you do not have the required hours, your complete application will be returned and you have 90 days from the date of the notification letter to re-submit the application without an additional fee.

GEORGIA STATE BOARD OF ACCOUNTANCY

237 Coliseum Drive - Macon, Georgia 31217 - (478) 207-2440

www.sos.state.ga.us/plb/accountancy/

APPLICATION FOR REINSTATEMENT OF LICENSE

(Application will be returned if all questions are not answered)

Reinstatement Fee: $150.00 (Non-Refundable)

1.Name on License

*THIS INFORMATION IS AUTHORIZED TO BE OBTAINED & DISCLOSED TO STATE & FEDERAL AGENCIES PURSUANT TO O.C.G.A. SECTION 19-11-1 & O.C.G.A.SECTION 20-3-295, 42 U.S.C.A. SECTION 551 & 20 U.S.C.A.SECTION 1001.

4.Physical Address

Number and Street (P.O. Box not acceptable)Apt. No.City/StateZip

7.Present Employer

8.Business Address

9.Internet e-mail address

Since the date of your last renewal, have you been convicted of a felony or misdemeanor (other than a minor traffic violation), or entered a plea of guilty, nolo contendere, or sentenced under the “First Offender Act’, or been sanctioned by this or another state board or agency? If Yes, check below and attach copy of conviction, plea or sanction. DUI and DWI are not minor traffic offenses.

ACTIVITIES SINCE LAST RENEWAL:

IMPORTANT: Please see the following for continuing professional education report & page 8 for copy of rule #20-10- 04.

CONTINUING PROFESSIONAL EDUCATION REPORT

NAME :

THIS PAGE MUST HAVE TOTALS FOR A & A HOURS AND ALL OTHER SUBJECTS HOURS. APPLICATION WILL BE RETURNED IF THESE COLUMNS ARE NOT COMPLETE. THE BOARD WILL NOT TOTAL YOUR CPE HOURS.

(See page 8 for copy of rule #20-10-.04 (REINSTATEMENT) effective January 25, 2001 for current requirement.) YOU ARE NOT REQUIRED TO SUBMIT DOCUMENTATION OF CONTINUING EDUCATION HOURS UNLESS YOU ARE AUDITED.

Sub Total Hours

TOTAL HOURS CLAIMED ABOVE 2 COLUMNS MUST BE COMPLETED

I certify under penalty of perjury to the truth and accuracy of all statements, answers and representations made in this report.

APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT YOU POSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR APPROPRIATE DOCUMENTATION.

Name

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2

Issued August 1, 2011 by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot later than August 1, 2011, the Attorney General shall provide and make public on the Department of Law’s website a list of acceptable secure and verifiable documents. The list shall be reviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(f). The Attorney General may modify this list on a more frequent basis, if necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G.A. § 50-36-2, contains documents that are verifiable for identification purposes, and documents on this list may not necessarily be indicative of residency or immigration status.

A United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the

Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A tribal identification card of a federally recognized Native American tribe, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer. A listing of federally recognized Native American tribes may be found at: http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/index.htm [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An Employment Authorization Document that contains a photograph of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A passport issued by a foreign government [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

A NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A. §50-36-2(b)(3); 22 CFR § 41.2]

A driver’s license issued by a Canadian government authority [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-560 or Form N-561) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

In addition to the documents listed herein, if, in administering a public benefit or program, an agency is required by federal law to accept a document or other form of identification for proof of or documentation of identity, that document or other form of identification will be deemed a secure and verifiable document solely for that particular program or administration of that particular public benefit. [O.C.G.A. § 50- 36-2(c)]

RULES OF THE GEORGIA STATE BOARD OF ACCOUNTANCY

20-10-.04 REINSTATEMENT

20-10-.04 Reinstatement. Amended.

(1)An application for reinstatement of an expired permit shall be accompanied by:

(a) A reinstatement fee of $150.00; and

(b)Evidence satisfactory to the Board, of the completion of continuing professional education as specified below:

1.Forty hours of continuing professional education for each year since the last renewal of the permit or since the initial issuance of the permit, whichever is less, up to a maximum of 160 hours.

2.At least twenty percent of the total hours required must be earned in accounting and auditing subjects.

3.At least 80 of the continuing professional education hours must have been completed during the 2-year period immediately preceding the date of application for reinstatement.

4.The hours required may be counted toward fulfilling the continuing professional education requirements for the next biennial renewal, if they were completed during the applicable period for renewal.

5.No carryover hours may be used to satisfy continuing professional education requirements for reinstatement of an expired permit.

(c)The Board may, however, accept in lieu of the continuing professional education requirements other evidence of continued competency including, but not limited to, the passing of an examination approved by the Board.

(2)In considering the application for reinstatement the Board may conduct an investigation of the applicant to determine, among other things, if the applicant engaged in the practice of public accountancy during the period that the applicant was not the holder of a live permit to practice public accountancy. Based on the results of that investigation, the Board may deny the application for reinstatement.