35611new_identity_card.pdf
Post on 07-Feb-2016
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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.
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