Annex II

FORM 1: APPLICATION FOR ASEAN CHARTERED PROFESSIONAL ACCOUNTANT (ACPA)

(To be completed by Applicant in BLOCK LETTERS)
Name of Accountant Applicant (As in Passport) : Dwi Arieyani Kusumawati,SE.Ak.CA
Name of Country of Origin : Indonesia
Academic Qualification Obtained : Bachelor Degree (S1)
Qualification Place and date obtained : UNIVERSITAS BRAWIJAYA/26 April 2003
NAB Membership / Accountant Registration No1. : CA. 11.D35797
(Country of Origin)
NAB Membership / Accountant Registration Date1 : 25 october 2018

ASEAN CHARTERED PROFESSIONAL ACCOUNTANTS Register (ACPAR):

Certified Compliance with ACPA Criteria:
1. Possess a Strata-1 (S-1) or Diploma IV (D-IV) from accountancy program which has
been accredited under prevailing education law and regulations. Overseas degrees
must be from an accountancy program which has been acknowledged with V
equivalence status by the relevant authority/-ies. 2

2. Possess a current and valid Professional Certification from IAI, IAMI, or IAPI; or V
license/registration from FPSC. 2

3. has at least three (3) years of relevant practical work experience cumulatively within V
a five (5) year period following graduation (see Annex III). 3

4. Fulfil CPD requirement from FPSC or relevant professional association (see Annex V
IV). 3

5. Does not have any record record of serious violation on technical, professional or V
ethical standards, either in Indonesia or elsewhere. 4

Applicant’s signature : ………………………………………………..

For Official Use Only
ACPA AMCI : …………………………… Meeting Date: ……………………………
(Name of Country of Origin)
Result : …………………………… Approval Date : ……………………
ACPA No : …………………………… Registration Fee : ……………………

Secretary General: ……………………..… Cashier/proof of

payment: ……………………
Note:
1. delete if not applicable
2. supply evidence in forms of official documents (or their legal copy) from relevant authority/institutions.
3. supply evidence in the standard form in the relevant annex or in other formats so long as they contain (1) the
information required in the standard forms and (2) be sufficently attested by relevant third/independent party where
applicable.
4. supply evidence in forms of official statement from relevant authority/institutions.
 Annex III

FORM 2: RELEVANT PRACTICAL EXPERIENCE FOR ASEAN CHARTERED PROFESSIONAL

ACCOUNTANTS REGISTRATION

Name of Accountant Applicant (As in Passport) : Dwi Arieyani Kusumawati

Name Title (Mr., Mrs, Ms., Ar., Dr.) : Mrs

Qualification Place and date obtained : UNIVERSITAS BRAWIJAYA/26 April 2003

License / Registration / Membership No*. : CA. 11.D35797

(Country of Origin)

License / Registration / Membership Date* : 25 october 2018

Qualification : Bachelor Degree (S1)

Date of Birth (DD/MM/YY) : 12/09/1979

Mailing Address : Perumahan Pondok Jati DG.17

RT/RW 31/ IX Jati Sidoarjo
Postcode : 61126
Country : Indonesia

Present Company/Organisation Name : KJA Dwi Arieyani Kusumawati,SE.Ak.CA

Company/Organisation Address : Perumahan Pondok Jati DG.17.
RT/RW 31/ IX Jati Sidoarjo
Postcode : 61126
Country : Indonesia

I wish to be registered on the ASEAN Chartered Professional Accountants Register (ACPAR) and
apply as described below in accordance with the provision that requires acquisition of relevant
practical experience of minimum three (3) years cumulatively within the last five (5) year period.
 Annex III

FORM 2
RELEVANT PRACTICAL EXPERIENCE FOR ASEAN CHARTERED PROFESSIONAL ACCOUNTANTS
REGISTRATION

Relevant Professional Accountancy Work Experience Record

Start Date / Organisation(s) / Responsibility / Scope of Work Attestant’s Information (Note 1)

End Date Position /
(Months) Designation Signature Relationship Tel / Email
to Applicant

03 Januari PT. Handal Yesindo  Prepare Monthly and Annual Direktur 031-
2008 s/d 31 Sejahtera Reports. 8438844
July 2017  Prepare the Daily Budget
Manager Tax  Validate financial and tax accounting
Accounting transactions. @handalye
 Apply tax and financial sindo.com
regulations to companies
 Monitor the company's
accounting and taxation system
internally.
 Manage and process data on
financial data and company tax
into reports

Note 1: The attestant above shall be, in principle, the representative of the organization which the
applicant has worked for.

To ASEAN Chartered Professional Accountant Monitoring Committee,

I hereby declare that the above descriptions are true to the best of my knowledge.

Signature :

Accountant Applicant's name : Dwi Arieyani Kusumawati,SE.Ak.CA

Date : 1 April 2019

 Annex IV

DECLARATION FOR THE APPLICATION ASASEAN CHARTERED PROFESSIONAL

ACCOUNTANT (ACPA)

I hereby declare that:

YES NO
I am an Accountant and complied CPD requirements V 

I meet the entire requirement as stated in Article 4 of the

ASEAN Mutual Recognition Arrangement (MRA) V 

No disciplinary action have been taken against me V 

I am not a bankrupt V 

Others:
………. ………. ………. ………. ………. ………. ………. ………. ……… ………

………. ………. ………. ………. ………. ………. ………. ………. ……… ………

………. ………. ………. ………. ………. ………. ………. ………. ……… ………

Yours Sincerely,

Dwi Arieyani Kusumawati,SE.Ak.CA

Name : Dwi Arieyani Kusumawati,SE.Ak.CA

Identity Card No. : 3573055209790006

NAB Membership / Accountant Reg. No. : IAI 11.D35797

Date : 31 December 2019