APPLICATION FOR EMPANELMENT AS CHECKER FOR THE CHARTERED
ACCOUNTANTS EXAMINATIONS [in response to Announcement Dated 1st October , 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 dated 1st October 2014, which I declare that have gone through the requirements and shall abide by them.
Fields marked with *
Name and Address for Communication of the Member ( ) IN
* ICAI Membership
* Date of Birth (dd-mm-yyyy):
* Date of Enrollment as
an associate Member:
5. Date of Admission as a Fellow Member
Other Communication Details:
* PAN (attach self
Banking details for payment purpose (a
cancelled leaf of unsigned cheque may be enclosed)
9. Whether your membership is LIVE as on date
membership fee paid for the current financial year):
I hereby declare that:
1. 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.
2. None of my relatives* or dependants* is / will be appearing in the CA [Final or Intermediate (IPC)] Examinations in November, 2014. [The term “relative” or “dependants” for the purpose of examination shall include in relation to an individual, the wife, husband, son, daughter-in-law, daughter, son-in-law, grandson, granddaughter, brother, brother’s wife, brother’s son, brother’s daughter, sister, sister’s husband, sister’s son, sister’s daughter, wife’s brother, wife’s sister and husband’s brother and husband’s sister”]
3. I am not an examiner for evaluation of answer books of CA Final and / or Intermediate (IPC) Examinations in November, 2014.
4. I am not coaching students for any of the examinations conducted by the Council of the Institute, in any Institute, in any institution / organization including Regional Councils / branches of the Institute and also private coaching, and
5. I am not associated with the Institute as an elected member of the Council / Regional Council / Branch managing Committee.
6. I have not been convicted by any court of law and that no disciplinary proceedings are pending against me either by the ICAI or by any other organization both in India and abroad.
7. A sample of my hand-writing in words as well as numerals is given below for reference and record purposes:
Membership No. _________
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.