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

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Joint Board for the Enrollment of Actuaries

5434

OMB Number

Form

Application for Enrollment

1545-0951

(Rev. January 2010)

Enclose with this form your check or money order for $250, payable to the Internal Revenue Service.

For Joint Board Use Only

By regular mail, send to: Internal Revenue Service, PO Box 301510; Los Angeles CA 90030-1510.

Enrollment No.

Date Enrolled

By overnight mail, send to: Box 301510; c/o Citibank; 5860 Uplander Way; Culver City CA 90230.

Read the instructions on page 3 before completing this form. Type or print.

1. Full legal name (Last, First, Middle)

2. Other names used (Including Maiden name and dates used)

3. Address (Number, Street, City, State, ZIP code)

4. E-Mail address

5. Daytime telephone number

6. Social Security Number

7. Date of birth (mm/dd/yyyy)

(optional)

8. How many months of responsible experience did you report on Schedule A (Employment Record)

(A) Responsible actuarial experience (from item (a) for all blocks of Schedule A) . . . . . . . . . . . . . . . . . . .

Month(s)

(B) Responsible pension actuarial experience (from item (b) for all blocks of Schedule A) . . . . . . . . . . . .

Month(s)

9. On what basis did you satisfy the basic actuarial knowledge requirement of section 901.13(c)

Joint Board basic examination(s)

Name(s) of exam(s), month(s) and year(s) completed

Waiver of Joint Board basic examination

Date waiver received

Qualifying formal education

Organization basic examination

Other

10. When did you satisfy the pension actuarial knowledge requirement of section 901.13(d)

Name(s) of exam(s), month(s) and year(s) completed

Yes

11. Have you previously applied for enrollment by the Joint Board

Yes

12. Have you read and are you familiar with the Joint Board's regulations

13. Have you timely filed your Federal tax returns and timely paid your Federal taxes for the

Yes

three tax years preceding your date of application

If No, provide details on a separate page.

14. In the last 15 years or since your 18th birthday, if sooner, have you ever been convicted or

Yes

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.

Declaration and Signature

I hereby apply to be enrolled as an actuary. I authorize the Joint Board to inquire about my qualifications and experience from educational institutions,

employers, supervisors, actuarial organizations, and any other individuals who may have knowledge related to my qualifications and experience. I

authorize all such institutions, employers, supervisors, organizations and others to provide any information requested concerning my education,

employment experience and qualifications as an actuary.

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.

15. Signature

16. Date signed

5434

Page 1 of 3

Department of the Treasury - Internal Revenue Service

Form

(Rev. 1-2010) Cat. Num. 42528L