2009 APPLICATION TO BE ENTERED ON THE RETIRED
MEMBERSHIP LIST IN THE REGISTER OF MEMBERS
ABN 64 008 392 452
MEMBERSHIP No.
NOTES
Notes to consider when completing this form:
1. Fees are payable with application and must be included with this form. Payment will only be processed if the reduction is approved.
(see ‘Payment’ section over page for fees)
2. In order to be eligible for transfer to the Retired List a member must have reached the age of 55 years; and
f no longer be engaged in gainful employment or business other than minor part-time activities
f no longer hold a Specialist Designation Certificate
3. Please complete in black ball point and use BLOCK LETTERS
4. Refer to By-Laws for full conditions (see over)
DETAILS
title Mr Mrs Ms Miss Other family name
first name preferred name
date of birth d d / m m / y y y y age in years telephone
email
private address
suburb
state postcode country
DESCRIPTION OF ACTIVITY
Do you hold a Public Practice Certificate? Yes No
Do you wish to cancel your Public Practice Certificate? Yes (please return your Public Practice Certificate with this application)
No (include an additional $150.00 PPF/LLS fee payment with this application)
Do you want to hold a Limited Practice Certificate? Yes No
Description of activity (if applicable - include hours per week)
DECLARATION
1. I hereby declare that I have read and comply with the Retired List By-Laws (over page).
2. I confirm the information provided on this application is true and correct and I make it in the belief that making a false declaration I can be
liable to the penalties of perjury.
3. I will notify CPA Australia if at any time I engage in gainful employment or business other than minor part-time activities and as such
become ineligible to remain on the Retired Membership List.
APPLICANTS SIGNATURE _______________________________________________ DATE d d / m m / y y
Page 1
PAYMENT
Australia = AUD116.00 (incl.GST) New Zealand = AUD119.00 (incl. NZ GST) Office Use Only Amount paid
Fees paid Date paid
Malaysia, Singapore, Hong Kong, China, Other overseas = AUD106.00 (excl. GST)
ROC number Transnet.
Please contact your Asian office for local currency information. (+Batch ID)
I am paying by cheque (make payable to CPA Australia Ltd and staple to your application form)
I am paying by the credit card AMEX Visa Mastercard Diners
CW/CVV
card number Number
expiry date / cardholder’s name
total $ cardholder’s signature
RETIRED MEMBERSHIP LIST BY-LAWS
3.6 (b) (ii) states that the members on the Retired Membership List can no longer hold a Specialist Designation.
3.7 A member may be placed on the Retired Membership List if the member:
(a) has attained the age of fifty-five (55) years and (as a continuing requirement) is not engaged in full-time gainful employment
(b) has made application in writing in the form from time to time prescribed for the purpose; and
(c) possesses such other qualifications or complies with such other conditions as the Board may prescribe either generally or in any
particular case.
and upon entry in the Register on the Retired Membership List a Member shall be:
(d) absolved from complying with:
(i) any Continuing Professional Development requirements of membership (unless the Retired Member, in any Annual Period
provides Public Accounting Services [whether or not for reward], or hold a Public Practice Certificate).
(ii) absolved from complying any requirement to hold current a policy of professional indemnity insurance unless providing Public
Accounting Services shall (whether or not holding current a Public Practice Certificate) hold current an enforeable policy of
professional indemnity insurance that satisfies at least the minimum requirements set out in By-Law 9.5(b).
(e) required to pay an annual membership renewal fee.
PRIVACY STATEMENT
In this Privacy Statement, “Personal Information” has the same meaning as in the Privacy Act 1998 (cth).
CPA Australia is committed to protecting the privacy and security of the Personal Information which it holds about you.
The personal information which you provide us with in this Application Form will be used by CPA Australia to:
f process your application to be entered on the Retired Membership List in the Register of Members
f update your membership details and profile information
f manage your membership of CPA Australia
f ensure your compliance as a member, with CPA Australia’s Constitution and By-Laws
If you do not provide us with this Personal Information, we may not be able to process your application.
You have the right to access any Personal Information which CPA Australia holds about you, subject to the expections in the Privacy Act 1998.
You may also request the correction of information which is inaccurate. Access and/or correction requests can be made at your local CPA
Australia office or via the CPA Online “Update your Profile” at cpaaustralia.com.au.
If you do not wish to receive material in relation to CPA events, please tick this box
If you do not want us to pass on your information to our business and marketing partners, please tick this box.
ADDRESSES
When completed, please return this form to:
AUSTRALIA SINGAPORE HONG KONG/CHINA MALAYSIA
CPA Australia Ltd CPA Australia Ltd CPA Australia Ltd CPA Australia Ltd
Member Administration 51 Cuppage Road 20/F Tai Yau Building suite 10.01, Level 10
GPO Box 2820 #10-06 StarHub Centre 181 Johnston Road The Gardens South Tower,
Melbourne VIC 3001 SINGAPORE 229469 Wanchai Mid Valley City, Lingkaran Syed Putra
AUSTRALIA Phone: +65 6836 1233 HONG KONG Kuala Lumpur 59200
Phone: 1300 73 73 73 Fax: +65 6836 2722 Phone: +852 2891 3312 MALAYSIA
Fax: 1300 78 76 73 Email: sg@cpaaustralia.com.au Fax: +852 2832 9167 Phone: +603 2267 3388
International fax: +61 3 9606 9844 Email: hk@cpaaustralia.com.au Fax: +603 2287 3030
Email: my@cpaaustralia.com.au
For further information, please visit cpaaustralia.com.au or contact your local CPA Australia office.
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MEMB00023 2008/10 CPA107779 10/2008