INSTITUTE OF INTERNAL AUDITORS INDIA

Membership Application Form

Personal Data:

Name: Mr / Mrs / Ms.
First Name Middle Name Surname

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 years 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. CIAs 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 undertake not to Mis-represent the Membership of The Institute.



Applicants Signature

Name:

Designation:

Date:

CLASSES OF MEMBERSHIP

The By Laws of The Institute of Internal Auditors, Inc., provide that the membership shall consist of several classes as may be
defined as necessary by the Board of Governors. These include such classes as Member, Associate Member, Educational
Member, Student Member, Honorary Member and Retired Member.


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 10.3% on 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 favor of Institute of Internal AuditorsIndia, Bombay Chapter payable at
Mumbai. (In case of Bombay Chapter)

The fees are for the year commencing 1
st
April and ending 31
st
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:






INSTITUTE OF INTERNAL AUDITORS INDIA
BOMBAY CHAPTER
ESGI Group Membership Application Form


Company Data


Name:

Address:



Phone No.

Members Data

Name of the Members Job Title Date of birth Professional Experience
(no. of years)
This company Previous
Companies











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 Audit reports:

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.



Applicants Signature Date:
Name & Designation


CLASSES OF MEMBERSHIP

The By Laws of The Institute of Internal Auditors, Inc., provide that the membership shall consist of
several classes as may be defined as necessary by the Board of Governors. These include such
classes as Member, Associate Member, Educational Member, Student Member, Honorary Member and
Retired Member.

Annual Membership Fee for the year 2011-12 - For Employer-Sponsored
Group of Individual Members (ESGI)

Fees
I II
Category 1to 5 members Above 5 members
Application fee (applicable only in the
first year of membership)
Rs. 5000 Rs. 1000 per member
Annual Membership Fee Rs. 10000 Rs. 10000 for 1
st
five
members plus Rs. 1400
per member above 5
members
Free copies of Internal Auditor Journals
(Hard Copy)
2 copies of every issue of
Internal Auditor Journal
2 copies of every issue
of Internal Auditor
Journal

Please make cheques payable to The Institute of Internal Auditors India, Bombay Chapter (In
case of Bombay Chapter)

The fees are for the year commencing 1
st
April and ending 31
st
March for the financial year, irrespective
of when the fees are paid.

PLEASE DO NOT WRITE BELOW THIS LINE

For Chapter Use only

Cheque No. dated for Rs. Rupees
only)

Deposited in Bank, Branch on /
/200


Signature of the Treasurer

Name:

Date:



Signature of the Chairman, Membership Committee
Name:
Date: