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NATIONAL COUNCIL OF INVESTIGATION & SECURITY SERVICES, INC.


                                      “Our Voice in Washington, DC and Across America”


                                           Mail to –P.O. Box 200615, Evans, CO. 80620-0615
                                   Email to – NCISS1976@yahoo.com     Fax to – (970) 480-7794



                                      Annual Membership Dues Renewal


                               Please note: If you joined before June 2015, your dues expire December 31st.
                             If you joined after June 2015, your dues expire annually on your anniversary date.

        Please verify that information is current on your NCISS profile.
        Login at www.nciss.org/login to verify your status, and securely pay your dues online from your profile.


               Please complete the following only if you have any changes and submit with your payment:


           Member Name: ______________________________________ Agency: ___________________________________________

                      Mailing Address: __________________________________________________________

                      City, State and ZIP: ________________________________________________________

                      Email Address: ___________________________________________________________


                       Office Phone: _______________________   Cell Phone:  __________________________

                       Amount Due – Regular / Gold   Affiliate    Associate     Service
                                     $175          $175           $75           $250
                            We now offer Auto Renewal – check here to authorize ___


                            (Association memberships – please contact Executive Director Karen Beers directly)

                                  NCISS CREDIT CARD AUTHORIZATION FORM

                         Member Name:

                         Credit Card No.:

                         Credit Card:              CVV No.       Expiration:       Billing ZIP:
                         VISA   MC   Amex



                         MEMBER DUES: __________ ( __ REGULAR  __ AFFILIATE  __ ASSOCIATE  __ SERVICE)

                         LEGISLATIVE DONATION: __________

                         AMOUNT TO CHARGE: _______________

                         Please consider a Legislative Fund Contribution and a donation of $5 to offset credit card processing fees
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