
Address Change Form
A separate address change notice must be submitted for each license type.
PLEASE PRINT
Name of Applicant for Licensure
Last First Middle
Individual (CPA/PA) - License No.
Name of Licensee
Last First Middle
Corporation
Name of Firm
Partnership Fictitious Name License No.
Firm Name
Be advised that if you are a licensed
NEW Address of Record
(An Address of Record is Required)
CPA/PA or firm, your address of record
is public information, and all CBA
correspondence will be sent to this
Business Name (if different from name above)
address.
Home Business (check one)
Street Apt. # Suite #
(check one)
City State Zip
Street
Former Address of Record
Apt. # Suite # (check one)
City State Zip
Alternate Address for Mail Drops and PO Boxes
If your address of record is a PO Box or Mail Drop, you are
required to provide a street address. This address will not be
posted on the CBA’s Web License Lookup.
Street
Apt. # Suite # (check one)
Home Business (check one)
City State Z
ip
-
Area Code
-
You may confirm your change of
address on License Lookup at
I certify the truth and accuracy of all of these statements and representations.
www.cba.ca.gov.
Signature Date
Daytime Phone Number
Print your name
A licensee who fails to notify the California Board of Accountancy
The CBA maintains a list of all licensees. This list is
within 30 days of a change of address of record may be subject to
sold to requestors for mailing list purposes. Check
here only if you do not want your name included on
citation and fine (fines ranging from $100-$1000) under the
this list. Please Note: Your name and address of record
California Code of Regulations, Title 16, Division 1, Sections 3,
is public information and can be accessed through our
95 and 95.2.
website at www.cba.ca.gov.
This form is being provided for your convenience. Other forms of written notice may be accepted by the CBA.
California Board of Accountancy, 2000 Evergreen Street, Suite 250, Sacramento, CA 95815-3832
Mail to:
or FAX to: (916) 263-3675