1. Applicant’s Name *
2. Gender *
3. Father’s/Husband’s Name *
4. Date of Birth *
5. Mailing Address *
6. E-mail Address *
7(a). Telephone Number(With STD Code) *
7(b). Mobile Number *
8. Fax Number
9. Current Occupation *
10. Details of educational & professional qualifications *
11(a). Do you possess minimum 15 years of senior-level experience in any sector/function in government/public/private sector or audit experience in a particular industry justifying to be an industry expert: *
11(b): If yes, please provide details thereof:Particulars of the organization working in/ have worked with (starting from last to first) -
Please provide Organization Name and Address, Phone No. of Organization (with STD code), Capacity of working [Please specify the position held in the organization], Working since [Please specify the period of working in the organization]
11(c) Area of specialization (please mention your field of activity/ specialization): *
11(d) Experience/ knowledge of the type of industry: *
11(e) Total experience (in no. of years) *
11(f) Details of experience at a senior management position (please specify the position, organization and period) *
11(g) Details of Directorships held in the past/present or audit experience in a particular industry justifying to be an industry expert *
11(h) Whether your brief profile/CV sent via email to *
12. Other professional achievements, if any *
13(a). Whether any disciplinary proceeding under the Chartered Accountants Act, 1949 pending against you or any disciplinary action under the Chartered Accountants Act, 1949 / penal action under any other law taken/pending against you during last three financial years and/or thereafter? *
13(b) If yes, please give details thereof:
I hereby declare that the information given above is true and correct to the best of my knowledge and belief and that nothing has been concealed therefrom.
Date *
Name *
Place *
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