Chartered Professional Accountants of Ontario69 Bloor Street East Toronto ON M4W 1B3T. 416 962.1841 Toll free 1 800 387.0735cpaontario.ca

Application for Membership on the Basis of Provincial Affiliation as a Student Form 4-1C All information required by this application MUST be completed in FULL by the applicant. Incomplete applications will NOT be processed.

This form is to be used by an individual who is applying for admission to membership with the Chartered Professional Accountants of Ontario (“CPA Ontario”) on the basis of Provincial Affiliation as a student.

For questions relating to this form, please contact CPA Ontario’s Customer Service at customerservice@cpaontario.ca or by telephone during business hours (Monday to Friday 8:30 a.m. – 5 p.m.) at 416 969.4322 or 1 800 387.0735, ext. 4322

CHECKLIST - REQUIRED DOCUMENTS

The following items must be submitted to CPA Ontario as one package. Items will not be accepted if sent separately. For each item listed below, please place a 3 in the box to signify that it is included as part of your application package.

To: Registrar, CPA Ontario

From:

Date Submitted (mm/dd/yyyy): / /

Please accept the following items as my completed application package:

FORM 4-1C – Application for Membership on the Basis of Provincial Affiliation as a student

Appropriate fee remittance as indicated in FORM 4-1C

CPA Ontario’s Academic Code of Conduct (cpaontario.ca/Resources/Membershandbook/1011page17801.pdf)

Proof of legal name. Satisfactory evidence of legal name includes a copy of any one of the following: birth certificate (or equivalent), passport, both sides of a Canadian citizenship certificate or card, both sides of a Permanent Resident card, or landed immigration papers. If the name under which you are applying is different from that which appears on the document submitted as proof of legal name, a copy of the document supporting the change of legal name, endorsed with “this is a certified true copy” signed and dated, is required.

Privacy Statement:

The information collected by this form is used for the purposes of application for admission. An individual has the right to privacy in respect of information of a personal nature known to CPA Ontario that is unrelated to the application for admission or not required to be disclosed in respect of the fulfillment of CPA Ontario’s regulatory responsibilities.

CPA Ontario may disclose your personal information to provincial or national accounting bodies for the purposes of providing services to firms, members, students and applicants and to third-party providers for the purposes of providing member benefits.

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A. Personal Information CPA Ontario ID (For internal use only):

Have you ever registered with CPA Ontario?

Student Ambassador Program Professional Development Course

Ordered Material Course or Degree Assessment

Registered Name – (must appear exactly as written on legal documentation)

Please note that the name provided below will be used by CPA Ontario in its record as your registered name.

Title (please select one): Mr. Mrs. Ms. Miss.

Surname: Given name(s):

Given name(s) used (if different from Given name above):

Former legal name: (name under which university degree was gained, if different from name noted above)

Date of Birth (mm/dd/yyyy): / /

Preferred Mailing Address:

City: Province/Territory/State:

Postal Code/Zip Code: Country:

Tel: Fax: Email:

Proof of Legal Name has been enclosed.

Please use this information for my preferred mailing and contact (e-mail and telephone number) information.

B. Personal Information

Employer Name:

Employer Address:

City: Province: Country:

Employer Tel: Employer Fax:

Email:

C. Basis of ApplicationI am applying for membership on the basis of my student registration with:

Name of Provincial Accounting Body:

Date of successfully completing the UFE or CFE (mm/dd/yyyy): / /

During my term of practical experience I have gained depth of experience in and breadth of experience in

and as documented in my Record of CA Qualifying Experience as

at (mm/dd/yyyy): / /

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All students are required to provide confirmation of their student registration. Such confirmation must be provided directly by the Provincial Accounting Body in prescribed form (The Provincial Accounting Body Confirmation: Application for Membership on the Basis of Provincial Affiliation as a Student Form 4-1D). Students are solely responsible for contacting their Provincial Accounting Body and requesting that confirmation be provided directly to CPA Ontario.

Are you a student in good standing? Yes No

* As you are applying as a student, please complete Education Information section below.

Degree(s) (BCOMM, BA, etc.) Name of University(s) Year Received (mm/dd/yyyy)

/ /

/ /

D. Good Character

Please respond to each statement listed below using only Yes or No. Please use a separate sheet to explain, in sufficient detail, all Yes responses. Please note that incomplete responses may lead to your application being deemed incomplete or the request for registration being denied.

1. Have you ever been convicted of a criminal offence or other similar offence for which a pardon has not been granted or are there any charges pending against you?

Yes No

2. Have you ever had a professional licence or permit suspended or revoked as a result of a disciplinary matter?

Yes No

3. Are you, or have you ever been, the subject of an investigation or a disciplinary decision or a form of settlement agreement by an academic institution or a professional body?

Yes No

4. Have you ever been expelled from a professional society or body (including legacy societies or bodies)?

Yes No

5. Have you ever made an assignment in bankruptcy, been declared bankrupt or taken the benefit of any statutory provision for insolvency?

Yes No

6. Have you ever been found guilty of a violation of securities regulatory regulation or tax authority regulation?

Yes No

For reference as to my character and integrity, I submit the names of the following two persons who are members in good standing of another Provincial Accounting Body not related to me and have known me for at least one year. I have contacted these individuals and have asked them to submit their recommendation.

Reference 1:

Full Name:

Address:

Tel: Email:

Occupation:

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Reference 2:

Full Name:

Address:

Tel: Email:

Occupation:

E. List any other provincial accounting bodies or accounting bodies where you have been a student or a member

Please provide a letter of good standing.

Name of Accounting Body Student/Member From (mm/dd/yyyy)

To (mm/dd/yyyy)

/ / / /

/ / / /

F. List all public accounting employment, as a student

Public Accounting Firm Name Address From (mm/dd/yyyy)

To (mm/dd/yyyy)

/ / / /

/ / / /

/ / / /

/ / / /

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G. Student Declarations & Consent

For each statement listed below, please signify your completion and/or acceptance of the requirement by placing a 3 in the box. Please note that incomplete declarations may lead to your application being deemed incomplete or the request for registration being denied.

I have read Regulation 4-1, Admission to Membership and confirm that I satisfy the requirements for admission to membership as noted in section 2.5.4.

I acknowledge that if approved for admission, I am subject to CPA Ontario’s Bylaws, Regulations, Rules of Professional Conduct and Academic Code of Conduct.

I acknowledge and agree that it is my responsibility to provide CPA Ontario with all required information and documentation acceptable to CPA Ontario and to pay to CPA Ontario the applicable fee for this application.

I acknowledge and agree that CPA Ontario may not consider this application to be complete in all respects and may not process, assess or accept this application if any of the required information or documentation acceptable to CPA Ontario has not been filed with CPA Ontario or if the applicable fee has not been paid to CPA Ontario.

I authorize CPA Ontario to verify the information provided or to obtain from the organizations concerned any information relevant to this application. I understand that any false or misleading statement contained in my application may be used by CPA Ontario in any proceeding respecting the validity of my application or my status as a student.

I authorize CPA Ontario to use this information for administration and regulatory purposes including but not limited to maintaining a comprehensive list of applicants and students registered in the CPA Certification Program, statistical and other data gathering purposes as well as other purposes related to maintaining the integrity of the CPA Certification Program. I understand that information contained in this declaration may be shared with CPA Canada for the same or similar purposes and by signing below, I hereby authorize CPA Ontario to share this information with CPA Canada.

I declare that the above information and all other information given in this application is true and correct.

X _____________________________ / /

Full name of applicant Signature of applicant Date (mm/dd/yyyy)

H. Fee remittance & payment options

Please provide a letter of good standing.

Amount Paid: HST# 10750 8525 RT0001

Important: Please do not email your credit card information. We are unable to process any credit card payment via email.

Credit Card or Interac: To pay by credit card or Interac please visit cpaontario.ca/pay4-1C

Personal Cheque: To pay by cheque, record your CPA Ontario ID on the cheque and make it payable to Chartered Professional Accountants of Ontario

Electronic Funds Transfer (EFT): Contact your financial institution to set up this option. The payment listing is available under “Chartered Professional Accountants of Ontario”. Please use your CPA Ontario ID as your account number.

Privacy Statement

CPA Ontario is committed to respecting your privacy and protecting your personal information. The collection, use and disclosure of your personal information that may be made by CPA Ontario is described in CPA Ontario’s Privacy Policy. The information collected in CPA Record Request is used primarily for the purposes of reinstatement of student registration.