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

Page 2

Schedule A (Employment Record)

Last name

First name

Middle name or initial

Account for the entire period of your employment in the actuarial profession within the last 10 years.

Block

1. Dates of employment

2. Exact title of position

3. Type of business or organization

(mm-yyyy)

From

4a. Provide the name, position title, address, email address (if known), and telephone number of your immediate supervisor who can

certify your responsible actuarial experience.

4b. If your experience includes responsible pension actuarial experience and your immediate supervisor is not an enrolled actuary, also

provide the name, position title, address, email address (if known), and telephone number of an enrolled actuary who can certify

your responsible pension actuarial experience.

5. Name of employer and address.

6. In your own words, describe IN DETAIL your actual duties and responsibilities in the above employment. Be sure to include all

relevant duties and responsibilities relating to those described in section 901.1. Estimate the proportion of the total period devoted to

each type of duty and responsibility.

Month(s)

6(A) How many months of this employment constitute "responsible actuarial experience" as defined in section 901.1(c)?

6(B) How many months of ''responsible pension actuarial experience'' as defined in section 901.1(e) are included in 6(A) above?

Month(s)

5434

Catalog Number 42528L

Form

(Rev. 3-2014)

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