CIA EXAM APPLICATION fORM

sTOP! If YOU HAVE ACCEss TO THE INTERNET, DO NOT UsE THIs PAPER APPLICATION fORM. INsTEAD, APPLY
ONLINE AT WWW.THEIIA.ORG/CERTIfICATION fOR PROMPT PROCEssING Of YOUR APPLICATION/REGIsTRATION.
Applications submitted online with credit card payment may be reviewed and processed within 72 business hours of submission. (Online application
and registration also offers options for check and wire transfer payment.) Applications submitted by mail may take several weeks to review and process.

Candidates from Argentina, Australia, Austria, Belgium, Brazil, Bulgaria, China, Chinese Taiwan, Czech Republic, France, Germany, Greece, Indonesia,
Israel, Italy, Japan, Korea, Malaysia, Mexico, Morocco, The Netherlands, New Zealand, Norway, Philippines, Singapore, South Africa, Spain, Sweden,
Switzerland, Thailand, or Turkey must refer to www.theiia.org/certification for candidate application and registration instructions.
NAME:
First Name Middle Name Last Name

Are you a member or prior customer of the IIA? Yes - ID # No - See pg. 2 for membership information

DATE Of BIRTH (mm/dd/yyyy): COMPANY NAME:

PREfERRED MAILING ADDREss: PRIMARY OR ALTERNATIVE
PRIMARY ADDREss: (For primary address, enter the address of the location where you currently reside or work for most of the year. Do not indicate addresses for temporary assignments or your declared
permanent residence address if it is not where you are located for most of the year. This address is required and must be accurate.)

City/State/Province/Postal Code/Country:
ALTERNATIVE ADDREss:
City/State/Province/Postal Code/Country:
PRIMARY PHONE NUMBER: Ext. PRIMARY fAX NUMBER:
Phone country code, number Phone country code, number, extension

PRIMARY EMAIL ADDREss:

PREfIX (Mr., Mrs., Ms.): sUffIX (Jr., Sr., III, other): GENDER: Male Female
JOB TITLE: JOB CODE: INDUsTRY CODE:

NAME As IT sHOULD APPEAR ON YOUR CERTIfICATE ONCE YOU ARE CERTIfIED:

*IIA chapter/institute where we should send your certificate once you have completed all of the program requirements. Please enter the chapter/institute that you have joined, will join, or is geographically
closest to you. A list of chapters/institutes is available on pg. 32 or at www.theiia.org/chapters-institutes/

EDUCATION: (Copy of degree or transcripts should be PRICING PROVIsIONs AND CONDITIONs: Applications Check or money order enclosed.
submitted with or directly following application.) and registrations will not be processed without payment. Prices are Charge to my: VISA MasterCar
Highest degree attained: subject to change. The IIA application/registration pricing is based on American Express d
the country provided in your primary address and your membership Discover
Each Application and Exam/Part Registration Fee will be charged
Bachelor’s degree (BS, BA, BCom, etc.) status. All fees are non-refundable. Please note that exam (part) regis- separately to your credit card.
trations will be valid for 180 days from the date that the registration is Card Number:
Master’s degree (MS, MA, MBA, etc.) processed at IIA.
Expiration Date:
Doctorate Application Fee
Member Non-member Full-time Other Signature:
Other Student/Professor
(specify degree and country in which it was attained) US $60 US $75 US $30* Wire transfer (Copy of wire transfer transmittal from issuing bank must
accompany application. Candidate’s name must be referenced on wire transfer.)
Year awarded:
Waived (See Special Offers at www.theiia.org/certification) Date Sent:
CERTIfICATIONs ATTAINED: Originator:
Exam/Part Registration Fees
(Check as many as appropriate. Note: must hold the final level of Amount Sent:
the certification.) Part 1 US $130 US $160 US $85*
CPA – State/Country: Part 2 US $130 US $160 US $85* PROGRAM PROVIsIONs AND CONDITIONs:
Part 3 US $130 US $160 US $85* By completing and submitting this form, I certify that I have read
CA – Country:
Part 4 US $130 US $160 US $85* and will abide by the provisions of the Code of Ethics (see pg. 34
CMA – Country: or online at www.theiia.org/guidance) and accept all conditions of
Part 4 Professional Recognition Credit
CGA the certification program for which I am applying.
(Must include documentation. See pg. 23.)
CISA
US $130 US $160 US $85* U.S. Federal ID#: 13-5532538
ACCA Waived (for CCSAs, CGAPs, and CFSAs) GST #: R124590001
Other: Wire Transfer – CNL Bank:
Account #: 3044773, Routing #: 063114289
If paying by wire transfer, add US $15.
ETHICAL sTANDING: In Canada, add GST/HST.
Check here if you have ever been convicted of a felony.
If paying by check drawn on bank outside Return to:
the United States and Canada, add US $30.
INTERNAL AUDITING EXPERIENCE:
TOTAL:
None Less than 1 year
CNL Bank
1 year but less than 2 years 2 or more years * Student fee must be accompanied by a Full-time Student/ P.O. Box 31280
Professor Status Form (see p. 35). Form and reduced price are
Tampa, FL 33631-3280
only valid for 180 days from the date that the form is
processed at IIA. or Fax: +1-407-937-1108
www.theiia.org/Certification If mailing by express mail, send to: The Institute of Internal Auditors,
247 Maitland Ave., Altamonte Springs, FL 32701-4201
U.S.A.
29