NEW MEMBERSHIP: Application

Please complete the following application:
(fields marked with * are required)

First Name*, Middle Initial, Last Name*:    
Rank/Title*:
Agency/Organization Name*:
Department/Section*:
Agency/Organization Leader's Name*:
Agency/Organization Leader's Title:
Agency/Organization Address Line 1*:
Agency/Organization Address Line 2:
Agency/Organization (City*, State Postal Code): ,    
Agency/Organization Country*:
Official Government or Business Email Address*:
Alternate Email*:
Agency/Organization Business Phone Number*:   Ext.  
Agency/Organization Alternate Phone Number:   Ext.  
Current Supervisor (Name/Title)*:
Current Supervisor Phone Number*:
Home Address Line 1:
Home Address Line 2:
Home (City, State Postal Code): ,    
Home Country:
Home Phone Number:
  I have attended the CFCE BASIC Conference.
Year Attended: 
  I would like my profile to be searchable by other IACIS members.
Requested Username*:
Password*:
Confirm Password*:
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