Application for CIPFA Affiliate membership

Title * Dr - Doctor Miss Mr Mrs Ms Mx - Non Gender Specific Other - Type your title in the box provided Other Title Forename(s) * Surname * Home Address Line 1 * Home Address Line 2 Home Address Line 3 Town * Country * Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Clipperton Cocos Cocos Keeling Islands Colombia Comoros Congo Congo the Democratic Republic of the Cook Islands Costa Rica Cote d Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Gabon Gambia Georgia Germany Ghana Gibraltar Gilbert Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Korea the Democratic People’s Republic of Korea the Republic of Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Burma Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine State Of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Portugese Guinea Puerto Rico Qatar Republic Of Ireland Republic of Maldives Reunion Romania Russian Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And The South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands British Virgin Islands US Wallis And Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe Post Code/Zip Code Telephone Number * Email Address * Mobile

I hereby certify that I have successfully completed a CIPFA accredited course leading to affiliate membership: Finance Business Partnering - Level seven certificate Diploma in Financial Skills (Finance training for School Business Managers) Open Book Processes Diploma in Corporate Governance CertFRA Certificate in Charity Finance and Accountancy Certificate in Public Sector Procurement Certificate in Contract Management Diploma in Audit Skills Diploma in Leadership and Management (Future Leaders Academy) Certificate in Investigative Practice Certificate in Asset Management Boardroom Leadership Programme DipIPSAS (and previous CertIPSAS) TIAPS Certificate (Training of Audit in Public Services) PACT Certificate (Public Accountants Certification Training) Are there any matters reflecting your competence or fitness of which the Institute ought to be aware? Yes No Are there any matters reflecting your competence or fitness of which the Institute ought to be aware? Yes No

This includes, but is not limited to:

• Being charged with an offence which has not yet come to trial
• Failure to satisfy a judgment debt
• An adverse finding against you by a professional body or regulator
• Any act or default which prejudicially affects the status,reputation or welfare of CIPFA
• Any act or default likely to bring discredit upon you, your employer, the Institute or the profession of accountancy

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 debits 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

Please note that CIPFA may make further enquiries of you and/or third parties in relation to the above disclosures in order to assess their impact on your application.

Job Title * Department * Organisation * Work Address Line 1 * Work Address Line 2 Work Address Line 3 Work Address Line 4 Town * Country * Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Clipperton Cocos Cocos Keeling Islands Colombia Comoros Congo Congo the Democratic Republic of the Cook Islands Costa Rica Cote d Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Gabon Gambia Georgia Germany Ghana Gibraltar Gilbert Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Korea the Democratic People’s Republic of Korea the Republic of Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Burma Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine State Of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Portugese Guinea Puerto Rico Qatar Republic Of Ireland Republic of Maldives Reunion Romania Russian Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And The South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands British Virgin Islands US Wallis And Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe Post Code/Zip Code Work Telephone Number * Work Email *

Please attach a Curriculum Vitae (CV) including where relevant details of

• Previous employment
• Educational qualifications
• Membership of professional bodies

I would describe my ethnic origin (not nationality) as Bangladeshi Black African Black Carribean Black Other Chinese Indian Pakistani White European White Other Other Other ethnic origin

You are under no obligation to supply the information sought here, but your co-operation is appreciated. CIPFA recognises the sensitivity of this information, which will be used for monitoring and statistical purposes only.

Date of Birth