CPA PROGRAM

SPECIAL CONSIDERATION APPLICATION

Submit only if you plan to attend or have attended the exam

PLEASE READ THESE INSTRUCTIONS CAREFULLY

This is an interactive pdf form. You can enter your details directly into the application form on your computer and then send us a printed and signed copy.
We recommend that you keep a copy for your own records. Applications received after the closing date will not be considered.
For application closing dates, please visit cpaaustralia.com.au/dates

WHAT IS THIS APPLICATION FOR?

Special consideration may be granted to candidates who are legitimately disadvantaged before or during their exam due to factors beyond their control.
Before applying for Special Consideration, please ensure you read the CPA Program Special Consideration Policy in full.
Special consideration is only available for candidates who have sat (or will sit) the exam.
Applications must include supporting documentation as evidence of your claims. If you are applying for special consideration because of a medical condition,
your medical practitioner or healthcare provider must complete section (F) of this form.
It is important that you outline the dates during which you were affected within your special consideration application. You must provide evidence that these dates were
during the semester or during the exam period.

(A) YOUR ELIGIBILITY

Did you sit or do you intend to sit your exam?  Yes Please note that you may only apply for Special Consideration if you select Yes for this option.
If you answered No, this application form is not relevant for your case. Candidates not intending
to sit an exam, can make changes to enrolment (such as exam cancellation or deferral) before
 No
the advertised closing dates at cpaaustralia.com.au/dates. More information about changes
to enrolment is available at cpaaustralia.com.au/change.

Are you requesting to defer or cancel your exam?

Special Consideration is not applicable to candidates who are requesting to defer or cancel their enrolment/exam. If you are requesting to defer
or cancel your enrolment/exam, please refer to the Subject Cancellation and Deferrals Policy on the CPA Australia website, noting you must
defer or cancel your exam prior to the advertised closing date. Please contact your nearest office to discuss your options. You will find a list
of our offices on the CPA Australia website at cpaaustralia.com.au/contact

(B) YOUR PERSONAL DETAILS

Membership number 10710122

Title Mr. First name Jagrit

Last name Jain Preferred name (optional)

This is mandatory.
Email address [email protected] Please ensure that your email
address is written clearly.

(C) SELECT SUBJECT FOR SPECIAL CONSIDERATION

Please tick relevant subject/s Date Time Location (full venue address or online)

Advanced Audit and Assurance / /

Australia Taxation – Advanced / /

Australia Taxation 1 7 / 0 4 / 2 0 2 1 2:00 PM IST Online

Contemporary Business Issues / /

Ethics and Governance / /

Financial Reporting / /

Financial Risk Management / /

Global Strategy and Leadership 2 1 / 0 4 / 2 0 2 1 2:00 PM IST Online

Singapore Taxation / /

Strategic Management Accounting / /

If you are applying for Special Consideration for more than one subject, and the grounds for your application are the same, please ensure you provide the exam time,
date and location for all relevant subjects.
If you are applying for Special Consideration for more than one subject, but the grounds on which you are applying for these subjects differ, please complete separate
application forms for these subjects.
2  |  CPA Program – Special Consideration Application (2021)

(D) REASON FOR APPLICATION

Please tick the reason for your application:

Medical condition Your medical practitioner or healthcare provider must complete section (F) with the details specified in section (E) of this form.

Personal hardship You must provide supporting documentation as specified in section (E) of this form

Exam incident You must indicate the exam date, time, location, and provide a detailed explanation below.

In your own words, explain the reason for your application. Please attach additional pages as required.

Explain in detail how you believe your studies and/or exam performance have been affected. Please attach additional pages as required.

(E) SUPPORTING DOCUMENTATION

Supporting documentation must be included in your application. It is your responsibility to provide supporting documentation.
Medical and Personal Hardship applications will not be processed without supporting documentation. The checklist below may assist in your application preparation.

  Is your documentation independent and objective? (e.g. manager, colleague, friend, neighbour, or doctor of your ill relative)
  Does the documentation refer to the impact on you?
  Has your documentation demonstrated that the hardship was beyond your control?
  Is your documentation current and relevant to the semester in which you are applying?

MEDICAL CONDITION

Applications for a medical condition must be supported by evidence of a consultation with your medical practitioner or healthcare provider.
During your consultation, your medical practitioner or healthcare provider must complete section (F) of this form and must state:
  The condition suffered (i.e. medical practitioner or healthcare provider must specify whether the condition is acute or chronic)
  Dates affected, and severity of the illness
  How, in your medical practitioner or healthcare provider’s opinion, your exam preparation and/or performance were affected.
It is highly recommended that your medical practitioner or healthcare provider provides detail of the dates affected in section (F) of the form.
Medical certificate in other formats from a medical practitioner will be accepted if it satisfies the above criteria.

PERSONAL HARDSHIP

You must include a letter, signed and dated, from someone not related to you by birth or marriage. The author must ensure the letter is written in their own words
and meets the following criteria:

  State the dates of the personal hardship

  Include how the hardship has impacted you/the applicant’s studies and/or exam performance
  Specify how they know you/the applicant (e.g. manager, colleague, friend, neighbour, or doctor of your ill relative)
  Letter needs to be on official letterhead or have the current contact details of the author (email, phone and/or address)
  Letter must be signed and dated by the author
  Where applicable, evidence your relationship to the deceased / ill relative

For Example: Personal hardship due to care of a sick relative is not sufficiently demonstrated with a medical certificate for that relative. You would need to include
independent supporting documentation as to how this affected you.

 lease provide any other supporting documentation that you feel will help your claim, such as, additional medical certificates, hospital admissions forms, a statutory
P
declaration or a police report.
Applications that do not contain detailed information within the third-party statement regarding how your exam preparation and/or performance has been impacted
may not be assessed by the Special Consideration Committee.
3  |  CPA Program – Special Consideration Application (2021)

EXAM INCIDENT

If applying on the basis of an exam incident, in section (D) you must provide:

  The exam date, time and location (venue or online)

  Full details of the exam incident including details of how it impacted your exam performance.

(F) MEDICAL CERTIFICATE TO SUPPORT SPECIAL CONSIDERATION APPLICATION

We strongly encourage candidates to use the medical certificate below when applying for special consideration for medical reasons. This certificate outlines the information
required to accurately assess your condition and its impact.
Only a medical practitioner or healthcare provider can complete this section.
For special consideration for medical reasons to be granted, CPA Australia requires information provided by a medical practitioner or healthcare provider.

TO BE COMPLETED BY MEDICAL PRACTITIONER/HEALTH CARE PROVIDER

Consultation date(s)

Summary of condition including how the candidate’s study and/or exam performance was or will be affected:

Period when the

candidate was or From To
will be affected

In my opinion, candidate is suffering from one of the following conditions:

  Acute/temporary condition    Chronic/ongoing condition    Acute/temporary exacerbation of a chronic/ongoing condition

In my opinion, the candidate’s performance was or will be affected:

 Mildly   Moderately   Severely

Indicate how your assessment of the candidate’s condition was obtained:

  Information provided by candidate    Examination of candidate

Practitioner/
Practitioner/Provider’s stamp
Provider’s name

Practitioner/
Provider’s number

Practice address

Suburb or City

State, Province
Postcode or ZIP
or Region

Country

Practitioner/
Provider’s signature
Date / /
 4  |  CPA Program – Special Consideration Application (2021)

(G) YOUR AGREEMENT

 I have read the Special Consideration policy at https://www.cpaaustralia.com.au/cpa-program/cpa-program-candidates/your-enrolment/rules-and-regulations/

special-consideration-policy
 I understand that my scaled exam mark must fall within a limited range below the 540 pass mark in order to be reviewed for Special Consideration, and that if
I receive a scaled score outside the limited range, my application will not be reviewed by the Special Consideration Committee and my result will not be considered
for adjustment.
  I have read, understood and agree to the Privacy Statement at https://www.cpaaustralia.com.au/utilities/privacy/privacy-policy

I request special consideration for the above subject exam(s).

Signature Date 0 7 / 0 5 / 2 0 2 1

Please print and sign. We do not accept digital signatures. By signing this form, you’re acknowledging you have supplied
everything that has been requested.
Unsigned applications will not be considered.

(H) SUBMITTING YOUR APPLICATION

FINAL CHECKLIST

  Did you sit /or do you intend to sit your exam?

  Did you sign the form?
  Did you supply documentation to support your application?
  Have you met the criteria outlined in section (E) applicable to the reason for your application?

WHERE TO SEND YOUR APPLICATION

Your application and supporting documents can be:

• scanned or photographed and emailed to [email protected]

* Please retain evidence of your lodged application (e.g. copy of email).

NB. You will receive an email confirming receipt of application. You will receive an email if we are unable to process your application due to lack of supporting
documentation. You will not be advised specifically of the outcome of your special consideration application.
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