Form "2"

[See Regulation 5(i)(a)]

The Institute of Chartered Accountants of India
Form of Application for Entry in the Register

To The Secretary The Institute

of Chartered Accountants of
India

Dear Sir,
I beg to apply that my name be entered in the Register. I hereby declare that I am not subject
to any of the disabilities stated in Section 8 of the Chartered Accountants Act, 1949. The
required particulars are furnished below:

1. Name in Full (Block Letters)

First Name
PIYUSH
Middle Name

Last Name
BERLIA

2. Father's Name
PAWAN KUMAR BERLIA

3.Date of Birth 20/06/1996 4. Nationality INDIAN

5.Educational Qualification

Result

Examination Board / University Year Marks Max Result

Obtained Marks Status

X CBSE 2012 475 500 Passed

XII CBSE 2014 569 600 Passed

Applicants are requested to produce evidence of their age.

Original diplomas/Certificates and/or other documents, or attested copies thereof, in support of qualification
must be sent with the application.
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 The year with the Roll Number(s) in which the applicant passed the various groups of
6.
the Final Examination:
Maximum Month Of
Group Details Roll Number Marks Obtained Year Of Passing
Marks Passing
DECEMB
Group 1 184055 218 400 2021
ER
NOVEMB
Group 2 265635 213 400 2020
ER
BOTH

The name of the Chartered Accountant(s) in practice or the frm of Chartered Accountants in
7a. practice under whom the applicant served as an Articled Assistant/ Audit Assistant. The period
service together with the date of commencements and termination may be indicated
Sr
.N Name of Member Member From Date/ To Date Status
o.

SOURABH KUMAR
1 415603 20/07/2017 / 19/07/2020 Completed
SINGH

Articles / Audit
7b. CRO0463069
Registration No.
Details of such other practical training which has been recognized by the council as
7c.
equivalent to practical training under the Chartered Accountants Regulations

Period of Residence
8. Years Months Days
in India

If not an Indian citizen, please state whether Certifcate of Indian Domicile has been
9.
obtained

10. Residential address

S/O. - SH. PAWAN KUMAR BERLIA , C/O. - M/S LAADLII SAREES , HOTEL
WAHEGURU COMPLEX AMBEDKAR CHOWK POST - WAIDHAN

City SINGRAULI State Code MP

Pin 486886 Phone No. with STD Code / 9910413657

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Country INDIA

Email Id PKBERLIA@GMAIL.COM

Mobile No. 8462887834

11 (a) Professional address

LAADLI SAREES , AMBEDKAR CHOWK ,

City WAIDHAN State Code MP

Pin 486886 Phone No. with STD Code /

Country INDIA

Email Id PBERLIA@GMAIL.COM

Mobile No. 8462887834

11 (b) Principal place of Business

, ,

City State

Pin

Country

11 (c) Other Places of Bussiness, if any:

1.

City State

Pin

Country

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2.

City State

Pin

Country

3.

City State

Pin

Country

Whether the applicant is incharge of the place or places mentioned at 11 above? If

12. not the name(s) and membership number(s) of the Institute who is/ are incharge of
that those place(s) and his/ their address (es).

If the applicant is a paid assistant to a Chartered Accountant in practice or in a firm of

13. such Chartered Accountants, name of the Chartered Accountant in practice or the firm
and from which date.

MRN / RFN Name of Member / Firm Date

If the applicant holds a salaried employment other than that covered by 13 above, full
14.
particulars thereof

Date of Joining Designation

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 Name of Employer

Address
City State Code

Pin

Whether the applicant intends to practice as Chartered Accountant under the Chartered
15.
Accountants Act, 1949.
N

Whether the applicant intends to continue the engagement at 13 or 14 above in the

16.
addition to practice.

Whether the applicant is engaged in any other business or occupation not covered by
17.
13 or 14 above, if so, full particulars thereof

Date from which

Engaged
Designation

Name of Concern / Company

Whether the applicant was at any time debarred from practicing as an accountant and if
18.
so, the reason and the period of suspension

Rea Peri Dat

son od : e

If the applicant wishes to practice in a trade or firm name particulars of the trade or firm
19.
name, as the case may be, with alternative in the order of preference

If the applicant had taken any loan scholarship from the Institute, the total amount of
20.
loan scholarship received, the amount paid off and the balance outstanding

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 N
Balance
Total Amount Amount Paid
Amount

I hereby undertake that if my name is entered in the Register, I shall be bound by the
21. provisions of the Chartered Accountants Act, 1949 and the Regulations framed here
under or that may hereafter from time to time be made pursuant to the said Act.

1 The details of fee paid is as follows:

Fee Description Fee Amount GST (as applicable)

MEMBER ENTRANCE FEE 2000
E-JOURNAL DISCOUNT -500
MEMBERSHIP FEE -
1500
ASSOCIATE

Tax (CGST) 9%
Tax (SGST) 9%
Tax (IGST) 18% 540
Total Amount (inclusive of taxes) 3540

Payment Status Payment Date

19/FEB/20
S
22

2. Documents submitted along with Form '2'

Attested copies of:
1. Letter of ICAI confirming completion of articled training.
2. Mark-sheets for both Groups of Final Examination of ICAI.
3. Date of Birth Certificate as per SSC/ Matriculation Examination.
4. Mark-sheet/ Degree of all Educational Qualifcations.
5. General Management & Communication Skill Course Certificate.
6. I-Card form duly completed.
If the Applicant is a Paid Assistant in a CA firm, please enclose a
7.
confirmation letter from the firm.
8. Copy of PAN Card
9. Copy of AITT certificate

Life membership of Chartered Accountant's Benevolent Fund

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I hereby also apply for Life Membership of Chartered Accountants Benevolent Fund.
Application in the appropriate is sent herewith.
I also send herewith Rs. 5,000/- towards the subscription of Life Membership of the
"C.A.B.F."

Signature (Old) Signature (Current)

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