Form 5434 - Application For Enrollment Form - Joint Board For The Enrollment Of Actuaries - 2010 Page 2

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Click here to create an additional Schedule A

Schedule A (Employment Record)

Start with your PRESENT position and work back. Account for the entire period within the last 10 years or, if shorter, since your completion of full-time

studies. Account for periods of self-employment in separate blocks in chronological order.

Block 1. Dates of employment (mm-yyyy)

2. Exact title of position

3. Type of business or organization

From

4. Name, position title, address, and telephone number of individual to whom you reported and who can verify and evaluate your experience

5. Name of employer and address

6. In your own words, describe IN DETAIL your actual duties and responsibilities in the above employment.

When more than one type of work is included, estimate the proportion of the total period devoted to each type.

(a) How many months of this employment constitute "responsible actuarial experience" as defined in section 901.1(c) . . . . . . . . . . .

months

(b) How many months of ''responsible pension actuarial experience'' as defined in section 901.1(e) are included in (a) above . . . . . .