The Institute of Chartered Accountants of India

Application Form for Member Identity Card

To,

The Secretary,

The Institute of Chartered Accountants of India

1. I hereby apply for issuance of Identity card of Membership.

2. That, I hereby declare that I had never applied for Identity card earlier nor it was issued to me.

3. That, I hereby agree to indemnify to keep ICAI harmless against all damages, losses, claims, costs

etc. which the ICAI may suffer, undergo, incur or pay as a result of misuse of this Identity card by any

act or omission.

4. The requisite particulars are submitted hereunder:-

Name : ________________________________________________________

(Fill in Capital letters)

Date of Birth :

Professional Address : ________________________________________________________

_____________________________________________________________________

City: _____________________ Pin Code ___________________

Phone No. : Office ____________________ Residence _________________

E-Mail Address (If Any) : ___________________________________________________

Date : ___________________________________________________

5. That my specimen signature and photographs are affixed hereunder: -

Note: Applicant is requested to paste two 4 Cms x 4 Cms of passport size color photographs mentioning name on the reverse

side of photographs.

4 Cms x 4 Cms Passport size

colour Photograph with White Background

Do not staple

Paste only

4 Cms x 4 Cms Passport size

colour Photograph with White Background

Do not staple

Paste only

Signature with Black Gel Pen Signature with Black Gel Pen

*Signature outside/overlapping the frame will not be accepted

Membership No.