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APPLICATION FOR EMPANELMENT AS CHECKER FOR THE CHARTERED ACCOUNTANTS EXAMINATIONS
[in response to Announcement No.13-CA (Exams)/CheckEmpanel/May-2014. Dated 18th March, 2014]

(This form is an application for empanelment only, making an application will not be construed as appointment as a checker)

I hereby give below my particulars for empanelment of my name to act as a Checker, in response to Announcement No.13-CA(Exams)/CheckEmpanel/May-14 dated 18th March, 2014, I declare that have gone through the requirements and shall abide by them:
(Please Affix a recent Passport size photograph.)
Fields marked with * are mandatory.
1. Name and Address for Communication of the Member (IN CAPITAL LETTERS)
 
a. * Name:
b. Address 1:
c. Address 2:
d. Address 3:
e. Address 4:
f. Place/Town/City (Please provide full name; do not provide short name):
g. District:
h. State:
i. * Pin Code:
2. * ICAI Membership Number:
3. * Date of Birth(dd-mm-yyyy):
4. * Date of Enrollment as an associate Member:
5. Date of Admission as a Fellow Member (if applicable):
6. Other Communication Details:
 
a. * E-mail ID:
b. * Mobile:
c. Phone (Office) (with STD Code):
d. Phone (Residence) (with STD Code):
7. * PAN (attach self attested copy):
8. Banking details for payment purpose (a cancelled leaf of unsigned cheque may be enclosed)
 
a. * Name of the Bank:
b. * Branch of the Bank with complete Address:
c. * Bank Account Number (12/16 digit account no. as applicable):
d. * IFSC Code:
e. * MICR Code:
9. Whether your membership is LIVE as on date
(i.e. membership fee paid for the current financial year):
DECLARATION
I hereby declare that the above information is true and complete to the best of my knowledge and belief. I undertake to keep the information/data/records/documents etc that might come to my knowledge/ possession as always confidential and secret and shall not divulge to anyone under any circumstance. I have read and understood the eligibility requirement(s) to become a checker, functions of checker, terms and conditions, etc. I understand that this assignment is of secret nature and I shall not divulge to anyone, not include such association in any manner in my bio-data or make public under any circumstances.
Station:__________ Signature:_________ Membership No. _________
Date:__________  Name: _________
Please send the print out with necessary enclosures to the following address: Shri G Somasekhar,
Additional Secretary (Exams)
Examination Department,
The Institute of Chartered Accountants of India,
'ICAI Bhawan'
C-1,Sector:1,
NOIDA-201301
Uttar Pradesh.
 
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