MEMBERSHIP APPLICATION

Membership Application
SECTION I: FIRM INFORMATION

1. Firm Name: ____________________________________________________________________________________

2. Principal Office Location & Contact Information:

» Address: _____________________________________________________________________________________
» City, State, Postal Code: _________________________________________________________________________
» Country: _____________________________________________________________________________________
» Phone: _______________________________________ Fax: _______________________________________
» General Firm Email: ____________________________________________________________________________
» Website: _____________________________________________________________________________________

Firm Managing Partner:

» Name: _______________________________________________________________________________________
» Title: ________________________________________________________________________________________
» Office Phone: _________________________________________________________________________________
» Mobile: ______________________________________________________________________________________
» Email: _______________________________________________________________________________________

Primary Contact / Partner-in-Charge (if different from Managing Partner):

» Name: _______________________________________________________________________________________
» Title: ________________________________________________________________________________________
» Office Phone: _________________________________________________________________________________
» Mobile: ______________________________________________________________________________________
» Email: _______________________________________________________________________________________

3. Total Staff ________

4. Total Offices ________ (if more than one office, please provide address and contact details for each)

SECTION II: FIRM REVENUE

5. Annual billing for last three (3) years: 20_____ USD $ __________________ % of growth ______%
20_____ USD $ __________________ % of growth ______%
20_____ USD $ __________________ % of growth ______%

6. Current year’s projected annual billing: 20_____ USD $ __________________ % of growth ______%

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- Membership Application
7. Percentage of gross fees attributable to:

» Audit ________%
» Accounting ________%
» Tax ________%
» Consulting ________%
» Other ________%
TOTAL 100%

8. Percentage of firm revenue coming from services to the following sectors:

» Services to listed companies: ________%

» Services to privately held companies ________%
» Services to government entities ________%
» Services to charities/non-profits ________%
» Services to individuals ________%
» Other ________%
TOTAL 100%

SECTION III: PERSONNEL

9. PLEASE PROVIDE (on separate paper) a brief Curriculum Vitae for all active Partners or other
licensed professional owners within the firm, providing the following information:

» Name
» Age
» Billing Rate/hr (optional)
» Area(s) of Professional Interest
» Office Phone
» Mobile Phone
» Email
» Present and past activities in the profession, both local and national (include offices held, committee chairmanships
at the local level and committee memberships at the national level)

10. Number of licensed/certified accountants within the firm: ______

11. Are all partners, CPAs, CAs or other licensed accounting YES NO
professionals in their country of practice?

If NO, please explain on Additional Information page.

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12. Are all partners members of the national professional YES NO
organization in their country of practice?

If NO, please explain on Additional Information page.

13. Are all partners members of their State or Provincial Society? YES NO N/A

If NO, please explain on Additional Information page.

SECTION IV: FIRM EXPERTISE

14. What are the top 5 industries and service areas/niches with which your firm has significant experience?

Industries Service Areas/Niches

___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________

15. In what languages is your firm able to conduct business and respond to requests for assistance?
_______________________________________________________________________________________________

SECTION V: FIRM STANDARDS

16. Has your firm or any partner been involved in litigation for YES NO
alleged non-compliance with professional standards, which
resulted in censure, reprimand, suspension or expulsion by
any professional organization or regulatory office?

If YES, please explain on Additional Information page.

17. Is your firm an affiliate of a national or international YES NO

organization of accounting firms, or does your firm have any
existing formal corresponding relationship with other firms?

If YES, please provide a brief explanation.

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- Membership Application
Applicant firm agrees:

» To be evaluated for membership based on the contents of the application and supporting documents
» To be subject to the Membership Standards of PrimeGlobal should admission occur

______________________________________________________________________________________________________
Name and Title of person completing this application

______________________________________________ ___________________________________________
Office Phone Mobile Phone

______________________________________________ ___________________________________________
Fax Email

______________________________________________ ___________________________________________
Signature Date

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Additional Information
Please use this page to provide additional information regarding your answers to the questions contained within this
Membership Application. Please specify the section and question to which you are referring.

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