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[in response to Announcement regarding Empanelment of Checkers for May, 2015 Examination Dated 20th March, 2015]

(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 for the same dated 20th March, 2015 which 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)

Please make sure that spellings are accurate

a. * Name: (example: I. K. Taneja)
b. Address 1: (example: Flat No.100)
c. Address 2: (example: Triveni Apartments)
d. Address 3: (example: Pitam Pura)
e. Address 4: (example: Near Ispat Bhavan)
f. Place/Town/City (Please provide full name; do not provide short name): (ex. Vellore, New Delhi or Jaipur)
g. District: (example: Nagpur)
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):
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 dependents* is / will be appearing in the CA [Final or Intermediate (IPC)] Examinations in May, 2015. [The term “relative” or “dependents” 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 May, 2015.
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. Associated with the Institute as an elected / co-opted member of the Council / Regional Council / Branch managing Committee or of any standing or non-standing committees of ICAI.
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. I understand that violation of terms & conditions of the assignment will attract disciplinary action under appropriate provision(s) of the Chartered Accountants Act, 1949 and regulations framed there under.
8. A sample of my hand-writing in words as well as numerals is given below for reference and record purposes:
In word:
In numerals:
Station:__________ Signature:_________ Membership No. _________
Date:__________  Name: _________
Please send the print out with necessary enclosures to the following address: Shri B. Muralidharan,
Deputy Secretary (Exams)
The Institute of Chartered Accountants of India,
'ICAI Bhawan'
Uttar Pradesh.
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