affiliate member counter fraud form

Title * First name * Last name * Home address line 1 * Home address line 2 Home address line 3 Town * County Country * Postcode/Zip code Telephone number * Mobile phone number Email address *

I hereby certify that * I am employed in a counter fraud and corruption role, or I am employed in a counter fraud and corruption role and my work includes interaction with law enforcement agencies and the criminal justice system. What qualification do you hold? Other Date of Qualifying * Accreditation number (if relevant, found on your Counter Fraud Professional Accreditation Board certificate) How many years have you worked in counter fraud? Are there any matters reflecting your competence or fitness of which the Institute ought to be aware? * Yes No Have you ever been disqualified as a Director anywhere in the world? * Yes No Have you been declared bankrupt anywhere in the world? * Yes No Have you ever undertaken an Individual Voluntary Arrangement or the equivalent in jurisdictions other than the UK between you and creditors to repay debts on a formal basis? * Yes No Have you entered into a composition with creditors or a deed of arrangement for the benefit of creditors in the UK or entered into equivalent arrangements outside the UK? * Yes No Have you ever been subject to any form of disciplinary proceedings in connection with either your employment or your membership of a professional body? * Yes No

Organization * Job Title * Department * Address Line 1 * Address Line 2 Address Line 3 Address Line 4 Town * Country * Postcode/Zip Code Telephone number * Email address *

I would describe my ethnic origin (not nationality) as Other ethnic origin Date of birth

I would like to receive emails about CIPFA products, services and events. * Yes No Membership communications are dispatched to each member's registered email address. I am happy to receive these notices in this way.* Yes No I would like to receive emails from carefully selected partner organisations that can support the public sector. * Yes No I would like to receive emails for the purposes of market research which will enable to us to better market our products and services. * Yes No

CIPFA Affiliate membership (counter fraud) application form