THE INSTITUTE OF CHARTERED ACCOUNTANTS OF INDIA NEW DELHI PEER REVIEW BOARD APPLICATION FORM FOR EMPANELMENT AS A
1. Applicant’s Name
Mr/Ms
FIRST MIDDLE LAST
2 Father’s Name
Mr
3 Date of Birth - -
DD MM YY
4. Mailing
Address
CITY STATE PINCODE
5. E-mail Address
6. Telephone Number -
Mobile Number
7. Fax Number -
8. Membership Number of ICAI
9. Associate Member Since - -
DD MM YY
10. Fellow Member Since - -
DD MM YY
11. Post-Qualification Courses Pursued (Conducted by ICAI)
Photograph
Name of Course Year of Completion
A Management Accountancy Course
B Tax Management Course
C Corporate Management Course
D Information and Systems Audit
E Insurance and Risk Management
F CAAT
G ITL & WTO
12. Any Major achievement (during education)
13. Audit working Experience (since enrolment as Associate):(starting from last to first)1
a. Firm Name and Address
Date of Constitution - -
Number of Partners
Number of Paid Chartered Accountants
Working as [Please specify the Position held in the firm of Chartered Accountant(s)]
[Please specify the Period of Working in the firm of Chartered Accountant(s)]
Working since
b. Firm Name and Address
Date of Constitution - -
Number of Partners
Number of Paid Chartered Accountants
Worked as [Please specify the Position held in the firm of Chartered Accountant(s)]
[Please specify the Period of Working in the firm of Chartered Accountant(s)]
From To
(Specify years only)
1
Use additional sheet, if required14. Major Attestation Work handled2:
Name of Client Level of
Responsib
ility
3Turnover
Fees
4 Audit5Type of Audits
(Tick appropriate Box)
(mention appropriate code) Statutory Tax Internal
/other
Banks
1.
2.
Financial Institutions
1.
2.
Insurance Companies
1.
2.
Companies
1.
2.
Public
1.
2.
Private
1.
2.
Co-operative Societies
1.
2.
NBFCs
1.
2.
Government15. Professional Achievements:
2
Use additional sheet, if required3
Please specify the level of responsibility as: Audit assistant-AS and Supervisory-SP.4
200 crore-2 and above 200 crores-3.
Please specify the Code for Turnover (per annum in rupees) as 1 to 50 crores-1; 50 to5
2 to 5 lacs-3 and more than 5 lacs-4.
Specify code for Audit fees per annum in rupees: upto 50 thousand-1; 51000 to 2 lacs- 2;16. Details of CPE Programmes attended:
17. Whether any Disciplinary action is pending against you
for enquiry)
Yes No
If Yes, please give details
(referred to Disciplinary Committee?I hereby declare that
a. I am a member of the Institute
b. I Possess minimum ten/fifteen years experience of audit and am currently active in the
practice of accounting and auditing
(Note: 10/15 years’ audit experience need not becontinuous but cumulative; but any block of less than 2 years’ experience in determining
cumulative experience shall not be counted)
c. The information given above is true and correct and nothing has been concealed therefrom.
Name
Date (Signature)
; andFor Office Use Only:
1. Whether applicant:
(a) Is member of the Institute Yes No
(b) possess atleast 10 years’ audit experience Yes No
(c) is currently active in the practice of accounting
and auditing Yes No
2. Whether applicant is to be considered for allotment of reviews of practice
units falling under:
All Stages of peer review
Stage III only
3. Whether complete information in the prescribed format is given in respect of
points:
13. Audit Working experience: Yes No
14. Major Attestation Work handled: Yes No
4. Whether all other applicable points of the form have been filled
Yes No
If No, Points …………………………………………………………………………………
5. Whether any Disciplinary action is pending
Yes No
6. RE No. allotted ………………..
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