Formulir Asean Cpa-2

Annex II
FORM 1: APPLICATION FOR ASEAN CHARTERED PROFESSIONAL

ACCOUNTANT (ACPA)
(To be completed by Applicant in BLOCK LETTERS)
Name of Accountant Applicant (As in Passport) : Radhi Abdul Halim Rachmat
Name of Country of Origin : Indonesia
Academic Qualification Obtained : Master
Qualification Place and date obtained : Widyatama University, 2012
NAB Membership / Accountant Registration No1. : 6240
(Country of Origin)
NAB Membership / Accountant Registration Date1 : …………………………………………….
ASEAN CHARTERED PROFESSIONAL ACCOUNTANTS Register (ACPAR):

Certified Compliance with ACPA Criteria:
1. Possess a Strata-1 (S-1) or Diploma IV (D-IV) from accountancy program which has
been accredited under prevailing education law and regulations. Overseas degrees
must be from an accountancy program which has been acknowledged with
equivalence status by the relevant authority/-ies. 2
2. Possess a current and valid Professional Certification from IAI, IAMI, or IAPI; or
license/registration from FPSC. 2
3. has at least three (3) years of relevant practical work experience cumulatively within
a five (5) year period following graduation (see Annex III). 3
4. Fulfil CPD requirement from FPSC or relevant professional association (see Annex
IV). 3
5. Does not have any record record of serious violation on technical, professional or
ethical standards, either in Indonesia or elsewhere. 4
Applicant’s signature : ………………………………………………..

For Official Use Only
ACPA AMCI : …………………………… Meeting Date: ……………………………
(Name of Country of Origin)
Result : …………………………… Approval Date : ……………………
ACPA No : …………………………… Registration Fee : ……………………
Secretary General: ……………………..… Cashier/proof of payment:

……………………
Note:
1. delete if not applicable
2. supply evidence in forms of official documents (or their legal copy) from relevant authority/institutions.
3. supply evidence in the standard form in the relevant annex or in other formats so long as they contain (1) the
information required in the standard forms and (2) be sufficently attested by relevant third/independent party
where applicable.
4. supply evidence in forms of official statement from relevant authority/institutions.
Annex III
FORM 2: RELEVANT PRACTICAL EXPERIENCE FOR ASEAN

CHARTERED PROFESSIONAL ACCOUNTANTS REGISTRATION
Name of Accountant Applicant (As in Passport) : …………………………………………..
Name Title (Mr., Mrs, Ms., Ar., Dr.) : …………………………………………..
Qualification Place and date obtained : …………………………………………….
License / Registration / Membership No*. : ………………………………………….…

(Country of Origin)
License / Registration / Membership Date* : …………………………………………….
Qualification : ……………………………………………
Date of Birth (DD/MM/YY) : …………../…………/…………………….
Mailing Address : …………………………………………..

…………………………………………..
Postcode : ………………………………..
Country : ……………………………….
Present Company/Organisation Name : …………………………………………….

Company/Organisation Address : …………………………………………….
…………………………………………….
Postcode : …………………………………
Country : ………………………………..
I wish to be registered on the ASEAN Chartered Professional Accountants Register (ACPAR)

and apply as described below in accordance with the provision that requires acquisition of
relevant practical experience of minimum three (3) years cumulatively within the last five (5)
year period.
Annex III
FORM 2
RELEVANT PRACTICAL EXPERIENCE FOR ASEAN CHARTERED
PROFESSIONAL ACCOUNTANTS REGISTRATION
Relevant Professional Accountancy Work Experience Record
Start Date / Organisation(s) Responsibility / Attestant’s Information (Note 1)

End Date / Position / Scope of Work
(Months) Designation Signature Relationship Tel /
to Applicant Email
Note 1: The attestant above shall be, in principle, the representative of the organization which
the applicant has worked for.
To ASEAN Chartered Professional Accountant Monitoring Committee,
I hereby declare that the above descriptions are true to the best of my knowledge.
Signature : ………………………………………………..
Accountant Applicant's name : ………………………………………………..
Date : ………………………………………………..
Annex IV
DECLARATION FOR THE APPLICATION ASASEAN CHARTERED

PROFESSIONAL ACCOUNTANT (ACPA)
I hereby declare that:
YES NO
I am an Accountant and complied CPD requirements  
I meet the entire requirement as stated in Article 4 of the

ASEAN Mutual Recognition Arrangement (MRA)  
No disciplinary action have been taken against me  
I am not a bankrupt  
Others:
………. ………. ………. ………. ………. ………. ………. ………. ……… ………
………. ………. ………. ………. ………. ………. ………. ………. ……… ………
………. ………. ………. ………. ………. ………. ………. ………. ……… ………
Yours Sincerely,
……… ……… ……… ……… ………................
Name : ……… ……… ……… ………..............................
Identity Card No. : ………......................................................
NAB Membership / Accountant Reg. No. : ..................................................................
Date : …….….....................................................

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Annex II

FORM 1: APPLICATION FOR ASEAN CHARTERED PROFESSIONAL

ASEAN CHARTERED PROFESSIONAL ACCOUNTANTS Register (ACPAR):

Applicant’s signature : ………………………………………………..

Secretary General: ……………………..… Cashier/proof of payment:

FORM 2: RELEVANT PRACTICAL EXPERIENCE FOR ASEAN

Name of Accountant Applicant (As in Passport) : …………………………………………..

Name Title (Mr., Mrs, Ms., Ar., Dr.) : …………………………………………..

Qualification Place and date obtained : …………………………………………….

License / Registration / Membership No*. : ………………………………………….…

License / Registration / Membership Date* : …………………………………………….

Date of Birth (DD/MM/YY) : …………../…………/…………………….

Mailing Address : …………………………………………..

Present Company/Organisation Name : …………………………………………….

I wish to be registered on the ASEAN Chartered Professional Accountants Register (ACPAR)

Relevant Professional Accountancy Work Experience Record

Start Date / Organisation(s) Responsibility / Attestant’s Information (Note 1)

To ASEAN Chartered Professional Accountant Monitoring Committee,

Accountant Applicant's name : ………………………………………………..

DECLARATION FOR THE APPLICATION ASASEAN CHARTERED

I hereby declare that:

I meet the entire requirement as stated in Article 4 of the

No disciplinary action have been taken against me  

……… ……… ……… ……… ………................

Name : ……… ……… ……… ………..............................

Identity Card No. : ………......................................................

NAB Membership / Accountant Reg. No. : ..................................................................

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