Cuban-American CPAs


	Application

First Name			Last Name
Email Address			Home Address
City			State	Zip Code
Home Phone			Home Fax
Birthdate (MM/DD/YY)			Place of Birth
Cuban Ancestry	Yes	No	Sex	Male	Female
Company Name			Business Address
City			State	Zip Code
Business Phone			Business Fax
Correspondence should be mailed to (Choose one)			Home	Business

Occupation:

Public Accounting (Choose One)

Sole Practitioner

Partner

Shareholder

Employee

Name of Firm
Title

Please indicate the number of professionals in firm:
Other than Public Accounting - (Please Describe)

Education	Degree	Year Obtained
High School
University
University

University
Other Degree
Other Degree

Prior Employment

Firm	Location	From/To

Professional Societies - Please indicate office held (if any) and committees

Other Organizations:

It is important to be active and make a contribution to the Association. We request that you indicate your interest(s) below. You must mark at least one.

CPA

CPA Certification No.:

Date Issued (MM/DD/YY)

State

Sponsorship:

Two members must sponsor you.

Member's Name	Certificate No.	Telephone

Applicant's Statement:

To the best of my knowledge and belief the information contained herein is true and correct.

Agree	Disagree	Date (MM/DD/YY):


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