SECOND SCHEDULE
[Under Regulation 6 of the Insolvency and Bankruptcy Board of India (Insolvency Professional) Regulations, 2016]

To
The Chairperson
Insolvency and Bankruptcy Board of India

Subject: Application for Registration as an Insolvency Professional

Sir/Madam,

I, having been enrolled as a Professional Member with the The Indian Institute of Insolvency professionals of ICAI hereby apply for registration as an insolvency professional under section 207 of the Insolvency and Bankruptcy Code, 2016 read with Regulation 6 of the Insolvency and Bankruptcy Board of India (Insolvency Professionals) Regulations, 2016. My details are as under:

A. Personal Details

Photograph (Passport-Size)
Title (Mr/Mrs/Ms) :
Name :
Father’s Name :
Date of Birth :
Place Of Birth :
Aaadhar No. :
PAN No. :
Passport No. :
Address for Correspondence :
City
State
Country
Permanent Address
City
State
Country
E-Mail Address :
Mobile Number :

B. Educational, Professional And Insolvency Examination Qualifications

1. Educational Qualifications
[Please provide educational qualifications from Bachelor’s degree onwards]
Educational Qualification
Year of Passing
Marks(%)
Grade / Class
University/College
Remarks, if any
Educational Qualification
Year of Passing
Marks(%)
Grade / Class
University/College
Remarks, if any
2. Professional Qualifications
Professional Qualification
Institute / Professional Body
Membership No. (if applicable)
Date of enrolment
Remarks, if any
Professional Qualification
Institute / Professional Body
Membership No. (if applicable)
Date of enrolment
Remarks, if any
3. Insolvency Qualifications
3.1. Have you passed Limited Insolvency Examination?
Attach Certificate
3.2. Have you passed National Insolvency Examination?

C. Work Experience

1. Are you presently in practice / employment?
2. Number of years in practice (in years and months) :
3. If in practice, address for professional correspondence :
4. Number of years in employment (in years and months) :
5. Experience Details (from the date of enrolment as Advocate / Chartered Accountant / Company Secretary / Cost Accountant/ Bachelors’ Degree)
SL. No. From Date To date Employment / Practice If employed, Name of Employer and Designation If in practice, practice as Advocate / Chartered Accountant / Company Secretary / Cost Accountant Area Of Work

D. Insolvency Professional Agency

1. Please give details of the insolvency professional agency with which you are enrolled as a professional member
2. Please state your professional membership number.

E. Additional Information

1. Have you ever been convicted for an offence?
If yes, please give details.
2. Are any criminal proceedings pending against you?
If yes, please give details
3. Have you ever been declared as an undischarged insolvent, or applied to be declared so?
If yes, please give details.
4. Please provide any additional information that may be relevant for your application.

F. Attachments

1. Copy of proof of residence
2. Copies of documents in support of educational qualifications, professional qualification and insolvency examination qualifications
3. Copies of documents demonstrating practice as
i. a chartered accountant enrolled with the Institute of Chartered Accountants of India;
ii. a company secretary enrolled with the Institute of Company Secretaries of India;
iii. a cost accountant enrolled with the Institute of Cost Accountants of India;
iv. an advocate enrolled with the Bar Council of any State in India;
4. Copies of certificate of employment from the employer(s), specifying the period of such employment.
5. Financial statement / Income Tax Returns for the last three years
6. Copy of certificate of professional membership with an insolvency professional agency.
7. Evidence of deposit/payment as applicable:
In Favour of
Insolvency and Bankruptcy Board of India
id
Amount (Rs.)
10,000
Cheque/DD No.
Date
Bank
parent_id
Proof of Deposit
In Favour of
Indian Institute of Insolvency professionals of ICAI
parent_id
Amount (Rs.)
11,800
Cheque/DD No.
Date
Bank
Proof of Deposit

G. Affirmations

1. Copies of documents, as listed in section F of this application form have been attached/ uploaded. The documents attached / uploaded are :
I undertake to furnish any additional information as and when called for
2. I am not disqualified from being registered as an insolvency professional under the Insolvency and Bankruptcy Board of India (Insolvency Professionals) Regulations, 2016.
3. This application and the information furnished by me along with this application is true and complete. If found false or misleading at any stage, my registration/ registration for limited period shall be summarily cancelled.
4. I hereby undertake to comply with the requirements of the Insolvency and Bankruptcy Code, 2016, the rules, regulations and guidelines issued thereunder, the bye-laws of the insolvency professional agency with which I am enrolled, and the resolutions passed and directions given by the Board and the Governing Board of such insolvency professional agency.
5. The applicable fee has been paid.
Signature of Applicant (Signature File)
Name of Applicant
Place
Date