1he Inst|tute of Chartered Accountants of Ind|a

ICAI 8nAWAN, ost 8ox No.7112, Indraprastha Marg, New De|h| - 110002
Lmall : examlnerpanel[lcal.ln WebslLe: www.lcal.org
App||cat|on for |nc|us|on of name |n the ane| of Lxam|ners for the Chartered Accountants Lxam|nat|ons
I. LkSCNAL DL1AILS:
1. NAML (ln full and noL lnlLlals) [ln caplLal leLLers surname lasL]
CA./ur./Mr.
/Ms./rof.
DD MM LAk
AIIIk
LA1LS1
ASSCk1 SI2L
nC1CGkAn
nLkL
2. AGL ?ears Date of 8|rth
3. AN NC
4. Deta||s for commun|cat|on:
kLSIDLN1IAL ADDkLSS: (for correspondence purpose) kLSLN1 CCCUA1ICNAL ADDkLSS WI1n DLSIGNA1ICN (for records purpose)
Cl1?: ln Cl1?: ln
S1A1L: S1A1L:
8LSluLn1lAL PCnL nC.
(Wl1P S1u CCuL)
ClllClAL PCnL nC.
(Wl1P S1u CCuL)
MC8lLL: MC8lLL:
L-MAlL: L-MAlL:
II. DL1AILS CI ACADLMIC]kCILSSICNAL UALIIICA1ICN:
S. rofess|ona| Membersh|p Deta||s:
(a) ACA M. no. uaLe lCA uaLe
(b) ACS M. no. uaLe lCS uaLe
(c) AICWA M. no. uaLe llCWA uaLe
6. Deta||s of Academ|c]rofess|ona| qua||f|cat|ons (|nc|ud|ng Law, Management, Informat|on 1echno|ogy etc.,) obta|ned
(|n the order of h|ghest qua||f|cat|on):
Name of the exam|nat|on passed w|th d|v|s|on
and year of pass|ng
Un|vers|ty]Inst|tut|on Ma|n]Spec|a||sed
sub[ects, |f any
Name of Lxam|nat|on of Marks ]
kank awarded, |f
any
ear of pass|ng
LL8/LLM
M.8.A
hd
lnlC8MA1lCn 1LCPnCLCC?
ulSA/ul8M/l1L&W1C
C1PL8S:
III. DL1AILS CI LMLCMLN1]kAC1ICL:
7. Length of exper|ence
(|n years)
kAC1ICL SLkVICL 1LACnING
8. Area of rofess|ona| ract|ce and spec|a||zat|on
9. art|cu|ars of emp|oyment (|n descend|ng order start|ng w|th present]|ast emp|oyment)
Name of Crgan|sat|on
Irom 1o Des|gnat|on
Nature of dut|es
10. If you have taken]tak|ng c|asses organ|zed by the keg|ona| Counc||]8ranch of the Inst|tute]r|vate Inst|tut|on]r|vate Group
Coach|ng, p|ease g|ve deta||s (|n the past 10 years):
Sub[ect(s) Leve| of Lxam|nat|on
CL]ICL]IINAL
Durat|on
Inst|tut|on
Irom 1o
11. Sub[ect w|se exper|ence. lease aLLach a separaLe sheeL, lf necessary:
Nature of
Ass|gnment
Sub[ect
Standard of
Lxam|nat|on
Un|vers|ty]Inst|tut|on
Number of
ears]Months
Language
(Med|um)
Moderator
nead Lxam|ner
uest|on aper
Setter
Lxam|ner
1eacher
12. If you have ever served the Inst|tute of Chartered Accountants of Ind|a as Lxam|ner, p|ease g|ve deta||s:
Month and year of Lxam|nat|on (s|nce) Leve| of Lxam|nat|on
[L-I]L-II]CL]ICL]I|na|]
Sub[ect(s)
13. Whether you were removed from the pane| of exam|ners by ICAI at any t|me? If yes, p|ease prov|de deta||s:
14. Deta||s of pub||shed work, |f any:
1S. rof|c|ency |n Language(s) for Va|uat|on of Answer 8ooks [|ease t|ck (v)]
LnCLlSP Plnul 8C1P
16. Cho|ce of Sub[ect(s) (max|mum two on|y) |n order of your preference (|n wh|ch you have spec|a||zed]pract|ced]taught) for
Lmpane|ment of Lxam|ners: (kefer sub[ects over|eaf)
S.No. Name of Sub[ect(s) Lxam|nat|on Inter(IC)]I|na|
1
2
IV. C1nLk DL1AILS:
17. (|) Is]are any of your re|at|ve(s)
#
a|so an exam|ner for eva|uat|on of answer book of Chartered Accountants
IN1LkMLDIA1L (IC)]IINAL Lxam|nat|on?
?es no
(||) If yes, k|nd|y prov|de the deta||s:
S.No. Name, address, phone no. etc.
Leve| of Lxam|nat|on
IN1LkMLDIA1L(IC)]IINAL
Sub[ect(s)
18. |ease prov|de two keferences (mandatory):
l)
Name, address, phone no. etc.
ll)
Name, address, phone No. etc.
19. 1he approx|mate d|stance between:
8esldence and nearesL Speed
osL CenLre (kms)
8esldence and nearesL AlrporL (kms)
V. DLCLAkA1ICN:
l hereby solemnly declare and afflrm LhaL:
l) 1he parLlculars sLaLed above are Lrue and correcL and noLhlng has been concealed.
ll) lf l am empanelled, Lhe asslgnmenL glven wlll be performed wlLh uLmosL care devlaLlon and commlLmenL.
lll) l furLher afflrm LhaL l shall noL dlvulge or parL wlLh any documenL or confldenLlallLy of Lhe examlnaLlon asslgnmenL as
may be asslgned Lo me, from Llme Lo Llme, Lo any one dlrecLly or lndlrecLly.
lv) 1he examlnaLlon asslgnmenL ls confldenLlal and l wlll communlcaLe wlLh Lhe LxamlnaLlon ueparLmenL of Lhe lnsLlLuLe
only for maLLers perLalnlng Lo me as an examlner and noL wlLh any oLher person/enLlLy.
v) l wlll noL reveal my ldenLlLy as an examlner Lo anybody lncludlng Lhrough my resume/blo-daLa senL Lo any
organlzaLlon.
vl) l have noL been convlcLed by any CourL of law and no proceedlngs are belng conLemplaLed/pendlng agalnsL me elLher
by lCAl or by any oLher organlzaLlon boLh ln lndla and abroad.
vll) ln case my name ls lncluded ln Lhe panel of examlners and any lapse ls found on my parL or devlaLlon from Lhe
prescrlbed guldellnes/lnsLrucLlons Lo examlners lncludlng non-adherence Lo Lhe Llme schedule and unsaLlsfacLory
performance, l wlll be llable Lo be removed from Lhe panel of Lxamlners.
vlll) l am noL assoclaLed wlLh any coachlng lnsLlLuLlons/ln coachlng Lhe sub[ecLs of CA course.
lx) lf lL ls found LhaL any maLerlal facL ls mlsrepresenLed, concealed, fraudulenL ln naLure eLc., l undersLand LhaL Lhe same
wlll aLLracL dlsclpllnary acLlon under Lhe law of Lhe land.
x) My empanelmenL as an examlner ls aL Lhe sole dlscreLlon of Lhe lCAl and lCAl may wlLhdraw my name from Lhe panel
of examlners aL any Llme wlLhouL asslgnlng any reason.
lace________________ SlgnaLure:_______________________________________
uaLe ________________ name : _______________________________________
Notes:
1. CharLered AccounLanLs wlLh a mlnlmum of four years sLandlng ln pracLlce or ln servlce are ellglble Lo apply.
2. unlverslLy LecLurers/rofessors wlLh a mlnlmum of flve years Leachlng experlence are ellglble Lo apply.
3. ersons above 60 years of age are noL ellglble for empanelmenL as examlner.
4. 8rlef descrlpLlon of naLure of work (rofesslonal or 1eachlng) handled and handllng be aLLached.
3. Coples of Mark sheeLs/uegree/asslng cerLlflcaLe/CC/ oLher relevanL LesLlmonlals musL be aLLached.
6. ersons who are undergolng any course of Lhe lnsLlLuLe cannoL seek empanelmenL.
7. All columns musL be fllled ln or sLruck off lf noL appllcable, else such lncompleLe appllcaLlon wlll be re[ecLed.
8. 1hose who are noL empanelled earller or resLed/removed from Lhe panel are noL ellglble Lo apply agaln.
9. 1he empanelmenL process would Lake conslderable long Llme, say 4-6 monLhs and no lnLerlm correspondence,
ln meanLlme, wlll be enLerLalned.
*Def|n|t|on of ke|at|ve
1he Lerm relaLlve" for Lhe purpose of examlnaLlon shall lnclude ln relaLlon Lo an lndlvldual, Lhe wlfe, husband,
son, daughLer, daughLer-ln-law, grand son, grand daughLer, broLher, broLher's wlfe, broLher's son, broLher's
daughLer, slsLer, slsLer's husband, slsLer's son, slsLer's daughLer, wlfe's broLher, wlfe's slsLer and husband's broLher
and husband's slsLer".
SU8ILC1S ICk CnAk1LkLD ACCCUN1AN1S LkAMINA1ICNS
IN1LkMLDIA1L (IC) LkAMINA1ICN
[Lach paper of 100 marks excepL aper -7]
aper 1 Lo 6 = 100 marks each and aper - 7 = 30 marks each.
C8Cu - l :
aper - 1 AccounLlng
aper - 2 8uslness Law, CommunlcaLlon and LLhlcs
aper - 3 CosL AccounLlng and llnanclal ManagemenL
aper - 4 1axaLlon
C8Cu - ll :
aper - 3 Advanced AccounLlng
aper - 6 AudlLlng and Assurance
aper - 7
SecLlon - A" - lnformaLlon 1echnology
SecLlon - 8" - SLraLeglc ManagemenL
IINAL LkAMINA1ICN
[Lach paper of 100 marks)
C8Cu - l:
aper - 1 llnanclal 8eporLlng
aper - 2 SLraLeglc llnanclal ManagemenL
aper - 3 Advanced AudlLlng and rofesslonal LLhlcs
aper - 4 CorporaLe and Allled Laws
C8Cu - ll:
aper - 3 Advanced ManagemenL AccounLlng
aper - 6 lnformaLlon SysLems ConLrol and AudlL
aper - 7 ulrecL 1ax Laws
aper - 8 lndlrecL 1ax Laws