APPLICATION FOR EMPANELMENT AS OBSERVER AT EXAMINATION CENTRES CONDUCTING THE CHARTERED ACCOUNTANTS EXAMINATIONS TO BE HELD IN [ NOVEMBER / DECEMBER - 2012 ]

APPLICATION FOR EMPANELMENT AS OBSERVER AT EXAMINATION CENTRES CONDUCTING THE CHARTERED ACCOUNTANTS EXAMINATIONS TO BE HELD IN [ NOVEMBER / DECEMBER - 2012 ]

1.	NAME AND ADDRESS FOR COMMUNICATION OF THE MEMBER (IN CAPITAL LETTERS)
2.	MEMBERSHIP NUMBER
3.	WHETHER ACA or FCA
4.	DATE OF ENROLMENT AS MEMBER
5.	COMMUNICATION DETAILS:
	E-MAIL ID:
	MOBILE:
	PHONE (O) (WITH STD CODE):
	PHONE (R) (WITH STD CODE) :
	FAX NO. (WITH STD CODE)
	PAN NO.:
6.	CITY / ZONE WHERE YOU WISH TO BE ASSIGNED EXAMINATION DUTIES (Please refer enclosed centre list )	CITY NAME (including Zone, if any)

Date:

Signature of Member ___________________________

Place