REINSTATEMENT APPLICATION Share Reinstatement Application Name Date of Birth Gender Male Female Employer Title Business Address Street Address City State Zip Code Country Telephone Fax Email Home Address Street Address City State Zip Code Country Telephone Fax Email Have you been a resident of the United States for more than three years? Yes No If no, please provide a separate statement, on your letterhead, indicating the need for your association with the Academy and familiarity with U.S. practices. Attach Separate Statement if Needed One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Send mail to: Business Home Your Background 1. Membership Education Requirements Status in other actuarial organizations (current membership isn’t required): American Society of Pension Professionals and Actuaries Level Date Attained Casualty Actuarial Society Level Date Attained Conference of Consulting Actuaries Level Date Attained Society of Actuaries Level Date Attained Other Please specify the name of the organization Level Date Attained 2. Are you an enrolled actuary? Yes No Enrollment Date Enrollment Number 3. Has any actuarial organization ever taken disciplinary action (i.e., reprimand, suspension, or expulsion) against you? Yes No If yes, explain 4. Date your Academy membership ended Reason: 5. Why do you want to renew your membership? Please submit the name and contact information of a member of the American Academy of Actuaries or another actuary who is subject to the Code of Professional Conduct who can detail and confirm your work and knowledge of applicable U.S. laws and practices. Reference First Name Reference Last Name Reference Organization Reference Title Reference Email Address Reference Phone Number Reference Actuarial Designations 6. Describe your actuarial experience in detail. Current Employer Name of Employer Name and Position of Immediate Supervisor Duties, and Actuarial Responsibilities Start Date (month/year) End Date (month/year) Years and Months of Actuarial Experience Years Actuarial Experiences Month Months Former Employer (1) Name of Employer Name and Position of Immediate Supervisor Duties, and Actuarial Responsibilities Start Date (month/year) End Date (month/year) Years and Months of Actuarial Experience Years Actuarial Experiences Month Months Former Employer (2) Name of Employer Name and Position of Immediate Supervisor Duties, and Actuarial Responsibilities Start Date (month/year) End Date (month/year) Years and Months of Actuarial Experience Years Actuarial Experiences Month Months Former Employer (3) Name of Employer Name and Position of Immediate Supervisor Duties, and Actuarial Responsibilities Start Date (month/year) End Date (month/year) Years and Months of Actuarial Experience Years Actuarial Experiences Month Months Former Employer (4) Name of Employer Name and Position of Immediate Supervisor Duties, and Actuarial Responsibilities Start Date (month/year) End Date (month/year) Years and Months of Actuarial Experience Years Actuarial Experiences Month Months 7. Have you ever been convicted of a felony? Yes No If yes, describe the facts and circumstances of the conviction on a separate piece of paper and return it with this application. A conviction does not automatically preclude you from membership in the Academy, but will be considered (with your explanation) as part of the reinstatement process. Application Statement: 1. U.S. Knowledge Attestation: I attest to necessary knowledge of U.S. laws and practices in my area(s) of actuarial practice with due consideration given to Precept 1 of the Code of Professional Conduct. 2. Reference Acknowledgment: I understand that an Academy representative may contact the individual (member of the American Academy of Actuaries or another actuary who is subject to the Code of Professional Conduct who can detail and confirm the applicant’s work and knowledge of applicable U.S. laws and practices) I listed on this membership application. 3. Professionalism Attestation: I attest that I have reviewed Professionalism for U.S. Actuaries, Outline of Concepts and Structure (as of October 2021) and the following related documents and I believe that I have a reasonable understanding of the items listed below: Code of Professional Conduct Qualification Standards (pages 1-8) The following documents related to Actuarial Standards of Practice (ASOP): ASOPs Nos. 1, 21, 23, and 41, and The Applicability Guidelines for my area(s) of actuarial practice; and Articles IX and X of the Academy’s By-Laws (relating to member discipline and the role of the ABCD) 4.If my application is accepted, I agree to be bound by the Academy Bylaws, Code of Professional Conduct, the Qualification Standards for Actuaries Issuing Statements of Actuarial Opinion in the United States, and by the Actuarial Standards of Practice of the Actuarial Standards Board. 5. I certify that the information provided for this application is, to the best of my knowledge, accurate and truthful. Your Full Name Date If you are approved for reinstatement, you will receive an invoice for annual dues.