Form 5434 - Application For Enrollment - Joint Board For The Enrollment Of Actuaries - 2004
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1
2
3Joint Board for the Enrollment of Actuaries
5434
OMB Clearance Number
Form
Application for Enrollment
1545-0951
(Rev. October 2004)
For Joint Board Use Only
Read instructions before completing - Please type or print. Mail to Executive Director,
Enrollment No.
Date Enrolled
Joint Board for the Enrollment of Actuaries, Department of the Treasury, Internal Revenue
Service, Washington, DC 20224.
2. Other Names Used (Including Maiden
1. Name (Last, First, Middle)
3. Social Security Number
Name and Dates Used)
4. Company Name
5. Home Address (Number, Street, City,
6. Date of Birth (Month, Day, Year)
State, ZIP Code)
4a. Office Address
7. E-mail Address
4b. Telephone number
8. Have you previously applied for enrollment by the Joint Board?
Yes
No
9. Have you read and are you familiar with the Joint Board's regulations?
Yes
No
10. Months of Experience Reported in Schedule A (See instructions on the back of this page)
Months
(A) Responsible Actuarial Experience from item (a) for all blocks of Schedule A . . . . . . . . . . . . . . . . . . .
(B) Responsible Pension Actuarial Experience from item (b) for all blocks of Schedule A . . . . . . . . . . . .
11. On what basis do you believe that you meet the basic actuarial knowledge requirement of section 901.13(c) of the regulations?
Joint Board basic examination. Month
Year
Organization basic examination(s) (please complete item 13).
Qualifying formal education (please complete Item 14). Have you requested all institutions involved to send transcripts to the
Executive Director of the Joint Board as required?
Yes
No
12. On what basis do you believe that you met the pension actuarial requirement of section 901.13(d) of the regulations?
Joint Board pension examination. Year
Organization pension examination(s) (please complete Item 13).
Exam
13. List all
When Taken
Exam
When Taken
Name of Actuarial Organization
Name of Actuarial Organization
Part No.
(month & year)
Part No.
(month & year)
actuarial
organization
examinations
passed. (See
instructions
on the back
of this page)
14.
Education in Accredited College and/or University
Years Attended
Degree
Major Area of Concentration
Year of Degree
Name and Location (City and State)
(B.A., etc)
From
To
15. In the last 10 years or since your 18th birthday, if sooner, have you ever been convicted or fined for a crime under any revenue law
or of a crime involving dishonesty or breach of trust? If yes, provide details on a separate page.
Yes
No
DECLARATION–I hereby apply to be enrolled as an actuary. I authorize the Joint Board to inquire about my
PLEASE NOTE–A willfully false statement
qualifications and experience from educational institutions, employers, supervisors, actuarial organizations,
or material omission in the execution of this
and any other individuals who may have knowledge related to my qualifications and experience. I authorize
application may be grounds for denial of
all such institutions, employers, supervisors, organizations and others to provide any information requested
your application or subsequent suspension
concerning my education, employment experience and qualifications as an actuary.
or termination of your enrollment as an
I hereby certify, that to the best of my knowledge, the statements contained in this application are correct.
actuary. Under Title 18, United States Code,
Section 1001 anyone who knowingly and
(See note on right)
If I am enrolled, I agree to comply with all regulations of the Joint Board, including the Standards of
willfully falsifies, conceals or covers up a
Performance contained in section 901.20 thereof.
material fact or anyone who uses a false
document or statement knowing it to be
17. Date
16. Signature
false is subject to a fine of $10,000 or five
years imprisonment or both.
Department of the Treasury – Internal Revenue Service
Catalog Number 42528L
5434
Form
(Rev. 10-2004)
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