CPA Newfoundland and Labrador New CPA Provincial Membership Form - PDF

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Chartered Professional Accountants of Newfoundland and Labrador 95 Bonaventure Avenue Suite 500 St. John s NL CANADA A1B 2X5 T F CPA Newfoundland and Labrador New
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Chartered Professional Accountants of Newfoundland and Labrador 95 Bonaventure Avenue Suite 500 St. John s NL CANADA A1B 2X5 T F CPA Newfoundland and Labrador New CPA Provincial Membership Form Name: Address: Employer Name: Position/Title: Phone (work): Phone (Home): I wish to apply for admission to the CPA Newfoundland and Labrador. I have successfully completed the following requirements as a student: (i) Education requirement: a. CPA Common Final Evaluation: (Year); or b. Legacy program: (Program), (Year) (ii) Practical Experience requirement: ( completed) Do you provide any of the following services to the public? Yes Audit Engagements* Review Engagements* Compilation Engagements Tax preparation/advisory Financial Advisory / Consulting No If you answered yes to any of the above, in which capacity is the service provided: Partner / Owner in public practice** Employment in public practice** Volunteer *Audit and Review Engagements are included in the Chartered Professional Accountants and Public Accountants Act definition of public accounting. If you provide these services as a partner/owner in public practice, or are otherwise responsible for signing audit or review engagement reports on behalf of the firm, you require a current public accountant licence through the CPA Newfoundland and Labrador. **If you provide any of these services to the public directly or through your employment, you are subject to the Service to the Public Fee. [Please turn over] I have enclosed / attached: Declaration for admission to membership. Two references from Chartered Professional Accountants in good standing in Canada who have known me for a minimum of one year. An Original, or certified copy of a Criminal Records Screening Certificate I agree that upon acceptance of this application for membership, I will be governed by the by-laws, regulations, rules of professional conduct and all other governing documents of the Association. I declare that the information given in this application is true and complete. DECLARATION FOR ADMISSION TO MEMBERSHIP (May 4, 2015) PART A: I declare that, except as noted below under Exception(s) : 1. I am currently in compliance with all of the requirements of any professional regulatory body 1 of which I am a member, including those related to continuing professional development, professional liability insurance, practice review or inspection, licensing and similar requirements, and I am, to the best of my knowledge and belief, currently in compliance with all of the requirements and related legislation of any other regulatory body 2 to whose governance I am subject; 2. with respect to any complaint, review, decision, agreement or any other matter related to the discipline process of any professional regulatory body or related to compliance with the requirements of any other regulatory body: a. to my knowledge, I am not currently the subject of a complaint or any type of investigation or review by any such body, b. I have not ever been disciplined by nor have I entered into any agreement to settle or resolve an alleged breach of the requirements of any such body, and c. I have not resigned from membership in or registration as a student of any such professional regulatory body in order to resolve a disciplinary matter, nor have I voluntarily withdrawn from governance by any other regulatory body in order to resolve an alleged breach of its requirements; 3. with respect to any breach or violation of any provision of the Criminal Code of Canada or a similar code of any other jurisdiction, or any securities or tax legislation of any jurisdiction: a. to my knowledge, I am not currently the subject of an investigation or charges in relation to such a breach or violation, b. I have not ever been convicted of such a breach or violation nor have I entered into a settlement agreement in order to resolve any such alleged breach or violation, and c. I have not ever been discharged after being found guilty or pleading guilty to charges in relation any such breach or violation; 4. with respect to registration as a student or member of any professional or other regulatory body in any jurisdiction: a. I have not ever been refused registration as a student or member of any such body, and b. I am currently registered as a student or member of the following such body(ies); Name of Regulatory Body 1 A professional regulatory body is a quasi-judicial body that sets and maintains standards of qualification, attests to the competence of the individual practitioner, develops skills and standards of the profession, sets a code of ethical standards and enforces its professional and ethical standards. Such a body has power to compel a person to appear and answer to disciplinary actions relating to compliance with its standards. Examples of professional regulatory bodies include, but are not limited to, accounting, legal, actuarial, investment, real estate, engineering and financial planning professions. 2 A regulatory body is a quasi-judicial body, other than a professional regulatory body as described above that has power to compel a person to appear and answer to charges relating to compliance with its requirements. In this context, such a regulatory body s requirements include legislation that it is empowered to enforce, whether against its own members or the public generally, codes of ethics, bylaws, regulations, professional or practice requirements and similar standards. Examples of regulatory bodies include, but are not limited to, competition, election, gaming, human rights, environmental protection and health and occupational safety bureaus, commissions and agencies. 5. with respect to any academic dishonesty infraction or other disciplinary matter related to current or previous registration as a student of any academic institution in any jurisdiction: a. to my knowledge, I am not currently the subject of a review in relation to any such matter by any such institution, and b. I have not ever been disciplined or involuntarily deregistered in relation to any such matter by any such institution; 6. I have never made an assignment in bankruptcy, been declared bankrupt or taken the benefit of any statutory provision for bankruptcy; and 7. with respect to an application for readmission to membership to the Association, I have not, since the date that I ceased to be a member of the Association, to the best of my knowledge and belief, engaged in conduct that, if engaged in by a member of the Association, could reasonably be considered to be a violation of the rules of professional conduct, bylaws, regulations, and enabling legislation of the Association/Ordre. Exception(s): Please note any exceptions to the above declarations and attach an explanation of the exception, including, as applicable, the name of the other body, period of registration and a brief description of circumstances related to any such exceptions. Item Number Name of Regulatory Body/Association/Statute PART B: 1. I declare that the information given in this application is true and correct. I acknowledge and agree that it is my responsibility to provide the Association with all required information and documentation acceptable to the Association and to pay to the Association any applicable fee for this application. 2. I authorize the Association to contact any organization identified in this application and consent to the release by any such organization of any information that is requested by the Association in order to properly consider this application. 3. I hereby certify that the personal information I have provided to the Association is accurate and has been freely given. I understand that the Association will protect this information in accordance with its privacy policy. 4. I understand that any false or misleading statement contained in this application may be used by the Association in any proceeding respecting the validity of my application or my status as an applicant or member of the Association. Admission to Membership Two References Required Referee s Recommendation 1 Re: Print Applicant s Name I am a Chartered Professional Accountant with membership in good standing in the province of Newfoundland and Labrador or (please indicate province if membership is another Provincial body).; I have known the applicant, who is not related to me, for years (minimum of one (1) year); I attest that (check boxes) I have found this applicant to be of good moral character and integrity; and I know of no reason why membership in the Association should not be granted. Please add any comments you believe will help in evaluating this application. Full Name of Referee (Please Print) Membership Number Admission to Membership Two References Required Referee s Recommendation 2 Re: Print Applicant s Name I am a Chartered Professional Accountant with membership in good standing in the province of Newfoundland and Labrador or (please indicate province if membership is another Provincial body).; I have known the applicant, who is not related to me, for years (minimum of one (1) year); I attest that (check boxes) I have found this applicant to be of good moral character and integrity; and I know of no reason why membership in the Association should not be granted. Please add any comments you believe will help in evaluating this application. Full Name of Referee (Please Print) Membership Number
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