Experience Verification Form
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1EXPERIENCE VERIFICATION FORM
INFORMATION ABOUT CANDIDATE
Candidate’s Name (Please Print):
______________________________________________________________________________________________________________________________
(Last Name)
(First Name)
(Middle Initial)
Candidate’s ID Number:_____________________________________
The individual named above has applied to the following certification program (check one) and must submit a completed, verified copy of this form in
order to complete the experience requirement, as outlined below:
Internal Audit Practitioner – 6 months of internal audit or equivalent experience (i.e., experience in audit or assessment disciplines, including
internal auditing, external auditing, quality assurance, compliance, and internal control).
CIA (Certified Internal Auditor) – 24 months of internal audit experience or its equivalent (defined as experience in audit/assessment
disciplines, including external auditing, quality assurance, compliance, and internal control).
Please check here if you have submitted a Master’s degree.
CCSA (Certification in Control Self-Assessment) – 12 months of control-related business experience, such as CSA, auditing, quality assurance, risk
management, or environmental auditing.
CFSA (Certified Financial Services Auditor) – 24 months of audit experience in a financial services environment.
CGAP (Certified Government Auditing Professional) – 24 months of auditing experience in a government environment (federal, state/provincial,
local, quasi-governmental areas, authority/crown corporation).
CRMA (Certification Risk Management Assurance) – 24 months of auditing experience or controls related business experience such as risk
management and quality assurance.
Professors: Two years of teaching experience in a related topic will be accepted as the equivalent of one year of work experience.
If teaching experience is being verified, list course titles, dates, and description of courses.
PLEASE COMPLETE THE FOLLOWING SECTION WITH EXPERIENCE INFORMATION.
PLEASE USE ADDITIONAL FORMS IF NEEDED.
Name of Organization: __________________________________________________________ Title: _________________________________________
Type of Industry:
Government
Financial Services
Other
Dates (Month/Day/Year) From: ____/____/____ To: ____/____/____
currently in this position
Check job duties:
internal audit
quality assurance
risk management
audit/assessment disciplines
compliance
external auditing
internal control
Other: ______________________________________________________________________________________________________________________
Name of Organization: __________________________________________________________ Title: _________________________________________
Type of Industry:
Government
Financial Services
Other
Dates (Month/Day/Year) From: ____/____/____ To: ____/____/____
currently in this position
Check job duties:
internal audit
quality assurance
risk management
audit/assessment disciplines
compliance
external auditing
internal control
Other: ______________________________________________________________________________________________________________________
INFORMATION ABOUT VERIFIER
I am (check all that apply):
A CIA
A CCSA
A CGAP
A CFSA
A CRMA
The candidate’s supervisor (current or prior)
Name (please print): __________________________________________________________________________________________________________
Title/Position: ________________________________________________________________________________________________________________
Organization: ________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________
Phone: ______________________________________________________ Fax: _________________________________________________________
E-mail: _____________________________________________________________________________________________________________________
STATEMENT OF VERIFICATION
I verify that the candidate named on this form has completed the experience as listed above, and I attest that this experience meets the experience
requirement of the program to which the candidate is applying, as outlined above.
Verifier’s Signature: ____________________________________________________________ Date: ________________________________________
Please upload the completed form through the document upload portal. Access the document upload portal by going to and clicking the link for
the document upload portal.
This document will be reviewed within approximately five business days of receipt at The IIA. You may confirm that the document has been approved by going to www.
, logging in to your record on the Certification Candidate Management System (CCMS), and clicking on the appropriate certification program on the
Certification Progress screen. If the document cannot be approved, you will be contacted.
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