The Institute of Cost and Works Accountants of India

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					                         The Institute of Cost and Works Accountants of India
                                        Cochin Chapter
                          ICWAI Bhavan, Judges Avenue, Kaloor, Cochin – 682 017

                          APPLICATION FOR THE ADMISSION TO ICWAI COURSE
                                          INTERMEDIATE
Session: January / July 20 ......                                                                                          FULL TIME

   1. Name (in Block Letters)* : ......................................................................
   2. Nationality*                              : ......................................................................
   3. Present Address*                          : ......................................................................
        ................................................................................................................
                                                                                                                                   Affix your Latest
        ................................................................................................................               Passport
       State*: ........................................ City*: ...................................................                 Photograph Here
       Pin code*: .................................. Phone No*: ..........................................
       Email ID...................................................................................................
   4. Age and Date of Birth*                    : ......................................................................
       Sex and Marital Status* : ......................................................................
   5. Name of Father/Guardian*:......................................................................
       Occupation of Guardian : ......................................................................
   6. Permanent Address*                        : ......................................................................
        ................................................................................................................
        ................................................................................................................
   7. Highest Exam Passed with Subject:* .......................................................
       University* .................................................................. Year* ..................
   8. Caste* :             SC          ST         OBC              Others
   9. Educational Background*:
                                                                                                                        Class &
                                                                                                                                            Total
   Examination passed with                             Name of the                   Name of the Board /               percentage
                                       Year                                                                                                 Marks
          subjects                                      Institution                     University                       of total
                                                                                                                                           obtained
                                                                                                                         marks




   10. Details of Certificates enclosed*:
          1. ................................................                          3. .........................................................
          2. ................................................                          4. .........................................................
   11. Are you a registered student of                       ICWAI                Reg.No. ............................. Dated ...................
       I.C.W.A.I Kolkata or any other
       Professional      Body       or                          ..............    Reg.No. ............................. Dated ...................
       Association? If yes, give                                ..............    Reg. No. ............................ Dated ...................
       Reg.No. and other details.
   12. Record of Extra Curricular Activities:




   * Fields are mandatory                                                                                                               (Over Leaf)
    13. Employment details, if any:
           Name of the employer        Period of Employment             Designation & nature of Job             Salary




    14. 4 Passport size Photographs of the applicant must be enclosed ( one must be affixed in the
        space provided and other must be attached with this application)
        Certified that the information given is true to the best of my knowledge and belief.



Place:                                                                                    Signature and Name of Student
Date:


                                                    DECLARATION

I ............................................................................................... hereby agree to keep regularly and
abide by all the rules and regulations of Cochin Chapter of ICWAI, SIRC of ICWAI and ICWAI. Also I
hereby declare that at present I am not a student of Postal Coaching of ICWAI.

Place:                                                                               Signature:

Date:                                                                                Name:

Note:

The Photostat Copies of Age certificate and all the years’ mark lists should be attested by any one of
the following under his/her seal and office seal.
    a) A member of Institute of Cost & Works Accountants of India or of the Institute of Chartered
         Accountants of India or of the Institute of Company Secretaries of India with his/her
         membership number.
    b) A Member of Parliament
    c) A Member of State Legislative Assembly
    d) A Gazetted Officer (A School Headmaster’s attestation is not acceptable)
    e) A Principal of College.




                                               FOR OFFICE USE ONLY


Roll No.                                                 Forwarded                               Other Details

Reg No                                                   Recommended

File No.                                                 Approved/Admitted

Date:                                                    Batch No:

Rt.No:                                                   Timing:

Amount

Date:

				
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