FORM OF APPLICATION FOR EMPANELMENT

1. Concern Name
(In case practicing in individual name, please mention the name in the CAPITAL LETTERS, please do not use prefix
M/s./Mr./Mrs. Etc. before the concern name.)
2. Status*
0 Sole Proprietary Concern/ Individual
1 Partnership Firm

3. Firm Registration No. (To be given in the case of a sole proprietary concern/
Partnership firm. (See also Note No. 1 at the bottom of this page)

4. P.A.N./G.I.R. No.
5. Service-tax Registration No. (See also Note No. 2 at the bottom of this page)
S. No. Service Tax Registration No. Place where Registered under the Service Tax Act.

6. Address (See Note No. 3 at the bottom of this page)

State/U.T.
Pin FAX NO.
Telephone No.
E-mail

* Tick appropriate Box

Notes:
1. Firm Registration No. of every sole proprietary concern/ partnership firm appears in the entry relating to the firm in the list of firm published by
the Institute. In the case of a member practicing in individual name, please mention “N.A.”
2. Details of Service Tax Registration No. are required to be filled up for Head Office as well as for Branch Office (s) also.
3. If full address, name of town, pin code and district is not filled in property, the application is liable to rejection.
4. Members/ Firm are required to fill-up their name, Address and Town in CAPITAL LETTERS ONLY.
7. Year of Establishment
(Please mention the year in which the firm was established. In case of individuals, the year of obtaining Certificate of Practice
should be mentioned.)

8. Particulars of Partners/ Sole Proprietor (Please fill up Annexure A)

9. Number of paid chartered accountant employees in the concern

Full Name
Part Time
Total
(Please fill up Annexure B)

10. Number of unqualified audit staff in the concern:

(a) Audit Clerks
(b) Articled Clerks
(c) Other audit staff
(Excluding administrative staff)
Total

11. Experience in Audit of Co-operative Sector in Delhi

(a) Co-op Societies
(b) Co-op Bank
(c) Other
(Experience of Last three years need to be mentioned)

12. Disciplinary proceedings pending against any partner/Proprietor (Yes/No), if yes

Name of Proprietors/ Partners Membership No. Brief Descriptions

(1)

(2)
 I/We, the undersigned, as Proprietor/Partners of M/s or as individual do hereby
declare that the particulars as given above including in Annexure A & B are complete and correct in all respect to the best of my/our
knowledge and belief. I/we further recognize that if any of the statements made therein or information furnished in the application
form is not correct, I/We would be liable for disciplinary action under the Chartered Accountants Act, 1949, and Regulations framed
there under:-

I/We hereby declare that audit/other assignment allotment on the basis of information furnished in the application form will
not be accepted and carried out if the firm in whose name the application is made is not in existence at the time of allotment.

I/We declare that the constitution of the firm as on (date) shown in the application is the same as that in
the construction certificate issued by the ICAI as on (date) in Case of any change, the details are given below
with a separate note.

S. No. Name of Partner/ Proprietor/ Membership No. PAN No. Signature

Individual

Date

Place

* 1. The declaration should be signed by the individual, or by the proprietor in the case of a sole proprietary concern, and by all the
partners in the case of a partnership firm.

2. The signatures should correspond to those in the Institute’s records.

Change is Status of the firm

 ANNEXURE A

Details of Partners/Sole Proprietor of the Concern

(In case a member practicing in individual name, particulars of such member to be given)

Name Membership PAN/GIR Whether Whether Whether Whether partner was previously Date of joining the Whether
No. No. Main partner/ full time employee of the firm as a partner/ association
Occupations proprietor/ applicant firm proprietor with the
is practice paid Yes No If Yes, please firm is only
employee in provide occupation
any other
concern
ACA FCA YES NO YES NO Date of Date of DD MM YYYY YES NO
Joining Leaving

TOTAL

* TICK THE APPROPRIATE BOX

Please give member number only, and not the region code (such as 100/200/300/400/500)
 ANNEXURE B

Details of Paid Chartered Accountant Employees in the Concern

Name Membership Date of Joining the Whether ARE THEY IN WHETHER PARTNER/
Number1 Firm SERVICE ON PROPRIETOR/ PART- SIGNATURE2
TIME EMPLOYEE IN
OTHER CONCERN
DD MM YYYY ACA FCA Full Part YES NO
Time Time
Basis Basis

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TOTAL

* TICK THE APPROPRIATE BOX

1. Please give membership number only and not the region code (such as 100/200/300/400/500)

2. The signatures should correspond to those in the institute’s records

 ACKNOWLEDGEMENT

Received Bio-data/ application form from M/s

On entered at Sr. No.

Signature of receipt clerk