^fe|^M6rnbership Application IIA/BANK USE ONLY

The iiistifLite i)t iufi-niiii Auditijn:

Tiidoii^la
For Office use only
liA Membership Number
IIA Chapter Number

li.^^MSiiiiess Diata
Please Type or Print Clearly

\7] Mr. □ M rs.

n Ms. I I Otiicr
Name: Feryanto Anthony
(Last) (First) (Middle) {Nickname)
Organization: KAP Johannes Juara dan Rekan .lob Title: Auditor
Address: Plaza Sentral 18th Floor, Jl. Jend. Sudirman 47 E-Mail : anthony.feryanto@inaaid.com
City: Jakarta Selatan Siaie/Provincc: DKI Jakarta
ZIP/Mail Code: 12930 Country: Indonesia
Business Phone: +62 21 5743025 Business FAX:
Job Code (see attached listings): Industry Code:
Do you spend more than 50 pereent of your time supervising other internal auditors or directing the audit program? Q Yes | | No
Number orinten!;il tiuditois on staff:

.-f •►'-•ft-:

l-Ionie Address: Jl- Cibubur Indah 2, Blok L/10 See dues payment information next page.
City: Jakarta Timur State/Province: l^l^l Jakarta Application fee Rp. 850,0 00,-
Zip/Mnil Code: 13730
Horne Phone: ^ Dues S(,
Mave yoti ever been convicted of a felony? □ Yes eT No Seminal- conicrence/credit
Arc yon a Ceriined liUenutl Auditor? □ Yes eT No
Other Designations:

Send Mail to: O Home Address 0^ Business Address

I I Check here, if you do no wisli your name included on TOTAL AMOUNT Rp. 850.000,-
mailing iisls other titan member mailings
Check One:

^ Payment enclosed. Please make checks payable

to The Instiliile oj'inlernal Aiulilors
Please select appropriate membership classification (see IH! Charge to my (circle one) :
inside for classification descri|ttion). ClassiUcalion is
Subject to determination by tlic International Membership
Committee.

M Regular Member (Please clteck one):

I I Internal Autliling Management CH [menial Auditing Staff
0 .Associate Mcmbci' Signatui'c:
I I F.ducation Membei-
I I Student Member. If apiilying as a sliident member,
please give the name of the college or university
you attend: I declare dial:
1 . All information contained on this ap|tlicalion is true
Date of Graduation: 2015 Degree: Master of Acc and eorrcei

List exact name to appear on membersliip certificate: 2. If accepted. 1 agree to abide by the Code ofEthics
adopted by the institute of Internal Auditors to govern its
Anthony Feryanto members.

Chapter AfUliation desired (If known. Sec back page):

Applicant's Signature:
Mcmbeisbip Sponsor (optional) 1
Date :
Member No.

• .V.