IIA MEMBERSHIP NUMBER: _______________________________

PERSONAL DATA																				
Name:										Mr.	Mrs.			Ms.				
Date of Birth:  |_|_|_|_|_|_|	Nationality:								Passport No: |_|_|_|_|_|_|_|_|_|_|_|		
				D  D M M Y  Y																				
	Home Address:																					
	Town/City:								Country:									
	Home Phone:							Email (personal):								
																										
	BUSINESS DATA																				
	Company:						Job Title:					Job Code: |_|_|_|		
	Address:																					
	Postcode: |_|_|_|_|_|_|  Town/City:										Country:							
	Business Phone: |_|_|_|_|_|_|_|_|_|_| Ext: |_|_|_| Fax: |_|_|_|_|_|_|_|_|_|_|		
																								
	Industry Code: |_|_|_|_|	Company Size by number of employees:	< 50	< 50-100	> 100		
	Head of Department’s Name/Designation:																	
	Number of Internal Auditors (in the company):									

	EXPERIENCE																				
	Do you spend more than 50% of your time supervising other internal auditors or							
	Directing the audit programme?											Yes	No				
	Number of years as an Internal Auditor |_|_|		Number of auditing personnel under your supervision	|_|_|_|			

Number of years in an Internal Audit supervisory position: |_|_|

EDUCATION

College / University:

Highest Qualification:

Year Obtained:  |_|_|_|_|

FOR SECRETARIAT USE

Date Received:					
Cash / Cheque No:					
Receipt No:		Signature:		
	Chief Executive Officer	
		Date approved:		

Checklist for Application

1.	Complete the Membership application form. 
2.	Ensure that the following documents are submitted together with: 

A.	Registration Fee and Annual Subscription 
B .A photocopy of your identity card / passport (for non-resident)

C. One current Passport size photo of yourself.

PLEASE NOTE THAT FEES MAY BE PAID DIRECTLY INTO OUR FNB BOTSWANA, GABORONE MAIN MALL ACCOUNT NUMBER6207 4956 007, BRANCH CODE: 282867 AND PROOF OF SUCH PAYMENT SUBMITTED TOGETHER WITH THE COMPLETED FORM.

APPLICANT’S DECLARATION & SIGNATURE

I declare that:

1.	All information contained in this application is true & correct, 

2.	If accepted, I agree to abide by IIA’s “Code of Ethics” and to support the “Standards for the Professional Practice of Internal Auditing”. 

Applicant’s Signature:		Date: