INSTITUTE OF INTERNAL AUDITORS – INDIA
BOMBAY CHAPTER
Membership Application Form for Individuals
This application should be submitted to
209, Sagar Avenue, 2nd Floor, Above ICICI Bank,
S.V.Road, Andheri (W), Mumbai - 400058. Email:
Personal Data:
Name: Mr. / Mrs. / Ms.
First NameMiddle NameSurname
Qualification(s):
Date of Birth:
Residential Address:
Residence Phone No:
Office Phone No:
Mobile No:
Email ID:
Professional Data:
Company:
Job Title:
Company Address:
Mail to be sent to your:Home ()Office ()
Broad Nature of Business: FMCG / Pharma / Engg. /Diversified / Others – Please specify:
No. of Employees in Company:
No. of Employees in Audit Department:
Name and Title of Person to whom you are Reporting:
No. of years in Present Company:
Previous Experience:
Name & No. of year’s Experience:
1)
2)
References:
Two references are required. It is preferable that one of these be from a member of Institute of Internal Auditors, Inc. The second reference should be from a business acquaintance. If you do not know a member of the Institute, give one personal reference and one business reference. CIA’s are not required to submit references.
1. Name: Mr. / Ms.
Designation:
Company:
Address:
Member of IIA: Yes
Membership No:
2. Name: Mr. / Ms.
Designation:
Company:
Address:
Member of IIA: Yes
Membership No:
I declare that:
1. All information contained on this application is true and correct.
2. I have read and will abide by the Code of Ethics adopted by Institute of Internal Auditors Inc, to govern its members.
3. I hereby undertake that I shall NOT USE any abbreviations like MIIA (USA), AIIA (USA) or FIIA (USA) with my name on my letter head or visiting cards as per restrictions imposed by IIA, Florida, USA. I further undertake that I will pay my annual subscription regularly in the beginning of the accounting year and in case my name is removed from the Membership Register of the Institute, I shall return the Membership Certificate and not misuse or Mis-represent the Membership of The Institute.
Applicant’s Signature
Name:
Designation:
Date:
FEES:
Admission fee (applicable only in the first year of membership): Rs.1000.00
Annual Membership Fee: Rs.1500/-
Total Fees Rs.2500.00
Plus Service Tax at 12.36% on the total amount of fees.
IIA JOURNAL- Hard Copy Rs. 1000/- for annual 6 issues. Also accessible online.
Those desirous of hard copy should include Rs.1000 along with the admission and subscription fee.
Please make Cheques/DD in favour of TheInstitute of Internal Auditors–India, Bombay Chapter payable at Mumbai.
The fees are for the year commencing 1st April and ending 31st March for the Financial Year, irrespective of when the fees are paid.
PLEASE FILL IN THE FOLLOWING PARTICULARS
Received From:
Cheque No:
Dated:
Rupees:.
Drawn On (Bank Name):
Branch: