Quality Review Board

[Established by Government of India under the Chartered Accountants Act, 1949]

APPLICATION FORM FOR EMPANELMENT AS A

TECHNICAL REVIEWER[1]

  1. Applicant’s Name

Mr/Ms

FIRST MIDDLE LAST

  1. GenderM F
  1. Father’s/Husband’s Name

Mr.

  1. Date of Birth --

DD MM YYYY

  1. Mailing

Address

CITYSTATE PINCODE

6. E-mail Address

Website

7. Telephone Number(With STD Code)-

Mobile Number

8. Fax Number-

9. Membership Number of ICAI

(Please enclose self attested photocopy of membership certificate)

10. Associate Member since --

DD MM YYYY

(Please enclose self attested photocopy of necessary certificate issued by the ICAI)

11. Fellow Member since --

DD MM YYYY

(Please enclose self attested photocopy of necessary certificate issued by the ICAI)

12. Details of other educational & professional qualifications, if any:

______

13. Other major achievements, if any:

______

14. Do you possess minimum fifteen years of post qualification experience and currently active in the practice of accounting and auditing:

Yes No

15. Audit working experience (during any 5 consecutive financial years):

  1. Particulars of the organization working in (starting from last to first)[2]:

Firm Name and Address

Firm Regn. No.

Capacity of working [Please specify the position held in the firm of Chartered Accountant(s)]

Working since [Please specify the period of working in the firm of Chartered Accountant(s)]

Date of constitution of the firm--

Number of Partners

Number of Paid Chartered Accountants

b. Have you handled as a signing partner/proprietor at least five statutory audit assignments as a Central Statutory Auditor of Banks/Statutory Auditor of Public Limited/Government Companies having annual turnover of rupees50 crores and above during any five consecutive financial years:

Yes No

c. If yes, please provide complete year-wise details thereof[3](Kindly give complete details specifying clearly the names of clients, year/s of audit, level of responsibility, turnover, type of audits etc.):

Name of Client / Year of Audit Assignment / Level of Responsibility[4] / Turnover
(`in crores) / Type of Audits
(Tick appropriate Box)
Statutory / Tax / Internal/other
Banks
1.
2.
Financial Institutions
1.
2.
Insurance Companies
1.
2.
Companies
  • Public

1.
2.
  • Private

1.
2.
  • Government

1.
2.
Co-operative Societies
1.
2.
NBFCs
1.
2.

16. Other professional achievements, if any. May also like to give details of position held by you as a Director/Chairman, Audit Committee in a Bank/financial institution/PSU/Company etc. :

______

17. Are you currently a Member of the ICAI’s Central Council/Regional Council/Branch level Management Committee:

Yes No

If yes, please give details thereof(specifying the exact position and the year for which it is being held):

______

18. Whether any Disciplinary proceedingunder the Chartered Accountants Act, 1949 is pending against you or any disciplinary action under the Chartered Accountants Act, 1949/ penal action under any other law has been taken/pendingagainst you during last 5 financial yearsand/or thereafter?

Yes No

If yes, please give details thereof:

______

I hereby declare that the information given above is true and correct to the best of my knowledge and belief and that nothing has been concealed therefrom and I am enclosing herewith a declaration of eligibility to act as a Technical Reviewer with the Quality Review Board.

Place:

Date:(Signature)

(Name______)

ICAI M. No. ______

Declaration of Eligibility to act as a Technical Reviewer with the Quality Review Board

I,………………………….(name) R/o…………………………………(address) hereby declare that:

a)I have a minimum fifteen years of post qualification experience as a chartered accountant and am currently active in the practice of accounting and auditing.

b)I have handled as a signing partner/proprietor at least five statutory audit assignments as a Central Statutory Auditor of Banks/Statutory Auditor of Public Limited/Government Companies having annual turnover of Rs. 50 Crores (Rupees fifty crores) and above during any five consecutive financial years.

c)I do not have any disciplinary proceeding under the Chartered Accountants Act, 1949 pending against me or any disciplinary action under the Chartered Accountants Act, 1949 / penal action under any other law taken/pending against me during last 5 financial years and/or thereafter.

d)I am, presently, not a Member of the ICAI’s Central Council/Regional Council/Branch level Management Committee.

I understand that any breach of the provisions regarding eligibility shall be considered as gross negligence and, may result in appropriate action under the Chartered Accountants Act, 1949.

Signature :

Name :

Address :

ICAI Membership No. :

Date :

Place :

Mobile/Phone No :

For Office Use Only:

  1. Whether applicant:

(a)is a member of the ICAIYes No

(b)possess atleast 15 years’ post qualification exp.Yes No

(c)is currently active in the practice of accounting

and auditing Yes No

(d)has handled as a signing partner/proprietor at least five statutory audit assignments as a Central Statutory Auditor of Banks/Statutory Auditor of Public Limited/Government Companies having annual turnover of Rs. 50 Crores (Rupees fifty crores) and above during any five consecutive financial years.

Yes No

  1. Whether complete information in the prescribed format is given in respect of pointno. 15:

(a)Audit working experience:Yes No

(b)Major attestation/internal auditwork handled: Yes No

  1. Whether all other applicable points of the form have been filled:

Yes No

If no, give details______

______

  1. Whether any disciplinary proceeding under the Chartered Accountants Act, 1949 is pending against the applicant or any disciplinary action under the Chartered Accountants Act, 1949 / penal action under any other law has been taken/pending against the applicant during last 5 financial years and/or thereafter:

Yes No

  1. Whether applicant is currently a Member of the ICAI’s Central Council/Regional Council/Branch level Management Committee:

Yes No

  1. Whether applicant is to be considered for allotment of reviews of audit firms:

Yes No

Remarks______

______

  1. TR No. allotted, if any ………………..

1 | Page

[1] Kindly furnish this duly filled-up application form alongwith necessary enclosures to the Secretary, Quality Review Board, Gr. Floor, Admin. Block, ICAI Bhawan, A-29, Sector 62, NOIDA-201309, Distt. Gautam Budh Nagar (U.P.). Email: ; Ph: 0120-3045983; Website: .

[2]Use additional sheet, if required

[3]Use additional sheet, if required

[4]Please specify the level of responsibility as: Signing Partner/ Proprietor - SP; Audit assistant- AS.