MEMBERSHIP APPLICATION YES! Please enroll me as a member of the Massachusetts Association of Public Accountants INSTRUCTIONS: Please print out this page, fill out the application and mail to MAPA at 607 North Avenue, D16, Wakefield, MA 01880. The application should be accompanied by your first year's dues, application fee, and required documentation as indicated*. Name ______________________________________________________________________ Name of Firm ________________________________________________________________ Mailing Address ______________________________________________________________ ___________________________________________________________________________ City/State/Zip_______________________________________________________________ Phone (_____)_______________________________________________________________ Email ______________________________________________________________________ Birth Date (optional) _________________________________________________________ Sole Practitioner Corporation Partnership Please provide a brief professional history ________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Applicants must meet at least one of the following qualifications for either FULL or ASSOCIATE Membership QUALIFICATIONS FULL MEMBER QUALIFICATIONS* Individuals of firms IN PUBLIC PRACTICE applying for Active Membership must be able to meet any one of the following requirements. Please check all of the following statements (A through D) that apply to you. A I possess a valid permit/license as may be granted under state law for the public practice of accountancy: Certified Public Accountant License No./State ________________________________ Public Accountant B Enrolled to practice before the I.R.S. (*Please provide a copy of your license.) Enrollment #______________________________________ C I possess an associate, baccalaureate or higher degree with a minimum of 24 semester hours in accounting. Highest degree: (*Please provide verification of your degree.) AS/AA = 2 year Degree MBA/MA/MS = Masters BA/BS = 4 year Degree PhD = Doctorate D I am accredited by the Accreditation Council for Accountancy and Taxationsm in: Accountancy Taxation Applicants for Full Membership must be at least 18 years of age, be a citizen of the United States, have at least two (2) years of experience in public practice and be able to furnish satisfactory references as to their experience, character and integrity. ASSOCIATE MEMBER QUALIFICATIONS Persons not meeting Full Membership qualifications may apply for MAPA ASSOCIATE membership. Check all statements below (E through G) which best apply to you. E I am a principal in an accounting/tax practice but I do not meet any requirements for Active Membership F I am an employee of an accounting and/or tax practice but I do not meet any of the requirements for Active Membership G I am employed in government, a financial institution, private sector business or non-profit entity and my primary duties are in the field of accountancy and/or taxation DUES DUES SCHEDULE + APPLICATION FEE INFORMATION* FULL MEMBERSHIP: (Must meet requirements of A or one of categories B, C, D) DUES: $150.00 Annually APPLICATION FEE: $75.00 (refundable if application rejected) ASSOCIATE MEMBERSHIP: (Must meet requirements E, F, or G) DUES: $100.00 Annually APPLICATION FEE: $50.00 (refundable if application rejected) *IMPORTANT NOTE: A copy of your professional stationery or business card MUST accompany this application. I hereby state that the accompanying statements are correct to the best of my knowledge and belief. I further state that I will abide bythe Constitution and Bylaws of the Association and will practice in strict conformity with the Code of Ethics and Rules of ProfessionalConduct adopted by the Association ______________________________ Applicant Signature ______________________________ Date Sponsor - (Optional) (Print or type) ______________________________ Name FOR MAPA USE ONLY Amount ____________________ Date Rec'd __________________ Control Number ______________