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Membership Application Form (Jul 2009)
Membership Application Form (Jul 2009)
Membership Application
1. Business Data
Please Type or Print Clearly Check if Internal Auditor magazine is subscribed
(For subscription detail, see Section 5)
Mr. Mrs. Ms
Address :
Do you spend more than 50 percent of your time supervising other internal auditors or directing the audit program? Yes No
Have you been a member of The Institute of Internal Auditors before? Yes / No
If yes : Name of The IIA’s Affiliate _____________________________________ Membership Id _______________________________
2. Personal Data
Home Address :
Postal Code :
Home Phone Cell :
Have you ever been convicted of a Yes No Certified Internal Auditor ? Yes No
felony ?
Qualification(s) : Academic: Professional:
Membership Classifications and Annual Fee are as follows (Please check one):
Regular (Management) : Managers and directors Regular (Staff) : Internal auditing staff (US $ 25)
engaged in internal auditing (US $ 25)
Associate : Corporate officers in other fields Education : Full time educators at colleges / universities
(US $ 25) (US $ 15)
Student : Engaged in full time study program Retired : Individuals who are retired and not in the employment
(US $ 15) any more (US $ 15)
Annual Subscription (July to June) for 6 issues of bimonthly magazine Internal Auditor is US $ 25. This is prorated for those
joining during the year, as follows:
Joining Month : Jul. & Aug Sep. & Oct. Nov. & Jan.-Feb. Mar. & May &
Dec. Apr. Jun.
Subscription Payable (US $) 25 21 13
17 9 5
Add applicable subscription amount to your membership fee to arrive at total dues payable (in Section 3).
6. Applicant’s Signature
I declare that all information contained in this application is true and correct. If accepted, I agree to abide by the Code of Ethics adopted by the Institute of Internal Auditors to
govern its members.