Page 9 - NCISS Privacy Special Report (March 2019)
P. 9

Referred by: __________________________________

                                                                                      National Council of
       P.O. Box 200615
       Evans, CO. 80620-0615                                                  Investigation & Security Services

       (800) 445-8408                                                                  Membership Application
       Fax: (970) 480-7794                                                      (Regular, Associate, or Affiliate)
       Email:                                                    Download this application at
                                                   MEMBER INFORMATION
      City:                                  State:                              ZIP Code:
      Business Phone:                        Fax:                                Cell Phone:
      Website:                               Date of Birth:                      Position with Company:
      E-Mail:                                                 Date Company was Established:
                                              LICENSING / AGENCY INFORMATION
      Does your state provide for licensing of investigators and/or private security personnel?     __ Yes    __ No
      Licensing Authority:                                                       Verification Contact:
      License No.:                           Expiration:                         State:
      Has this license ever been suspended?   Previously a NCISS member?         Have you been convicted of a felony?
           __ Yes    __ No                        __ Yes    __ No                     __ Yes    __ No (if yes, provide separately)
      Membership in national or state association?   Association:                Verification Contact:
           __ Yes    __ No                                                       (w/ Email or Phone)
      Check One:    Investigation    Security    Both  Association:              Verification Contact:
                                                                                 (w/ Email or Phone)
      Services you provide (list up to five, see NCISS Service Codes next page):
                                           MEMBERSHIP CLASSIFICATIONS AND DUES
        NCISS requires individuals to hold a valid license, when licensing is required, to conduct private investigation or security guard business,
                      or is an officer, partner or designated representative of a licensed investigative or security agency.
       __ Regular $175*                      __ Associate $75*                   __ Affiliate $175*
      A portion is directed to the legislative fund.    Individual not licensed and is an   Individual who holds an investigative or
      Receives all rights and privileges.    employee of a licensed NCISS        security position with a government,
                                             member agency.                      corporate or business entity.
      REGULAR & AFFILIATE ONLY - CHECK ONE:  *Plus $25 Non-Fundable Application Fee  Legislative Fund Donation
      __ Member Plaque or __ Padfolio        All applications are processed for required licensure   __ Please count on me to help defray the additional costs of
      (add $25 for both)                     and references.                     NCISS legislative advocate! I am donating $_____________
      Please list two business references, including one Investigation or Security company:
      Company:                               Contact:                            Email or Phone:
      Company:                               Contact:                            Email or Phone:
                                              COMPLETE THE NCISS APPLICATION
      __ Copy of Investigative or Security License / if not required - business registration information:
      __ Membership Dues (payable annually on anniversary date) - Credit Card No.
      __ Check (enclosed) or __ Credit Card   CVV No.            Expiration:                Billing ZIP:
                                                     AFFIDAVIT / WAIVER

      ___ The undersigned, does hereby certify that I am licensed by the   state or subdivision in which I do business (where licensing is required) and that I agree   to comply with all
      applicable federal and state laws within the scope of my business. I understand that maintaining a valid license is a prerequisite to both my admission as a member of NCISS and in
      continuing my membership. Should there be an action or claim against said license, I agree to furnish NCISS with all information relative to such claim or action. I agree to notify
      NCISS immediately of any convictions for criminal offenses regardless of nature. I also give my full consent  and authorization to NCISS, its officers or their agents to investigate
      such claim/action and inquire into my reputation, character and fitness for membership. I understand that submitting false information either as part of this application process or
      during any subsequent investigation will result in either the rescission or revocation of my membership. I hereby agree to release the above named organization, its officers,
      members and/or agents from all liability, claims, injuries (implied or actual) in matters emanating from any such investigation. I further agree that if my membership is rescinded
      or revoked for any reason, I will accept the  decision and expressly waive any right to  dispute that decision and agree to   waive any right to take any action, legal or otherwise,
      against the Association as a whole, its officers, directors, members or agents. Furthermore, I agree to abide by the Bylaws and Code of Ethics of NCISS and understand that any
      violation could result in suspension or revocation of my membership.
      __ I authorize auto-renewal of current dues on my joining anniversary date (credit card required / advance notice and invoice emailed)
      Signature of applicant (type if submitting electronically):                       Date:

                          -- This will create an encrypted data file as an email attachment in your  draft folder.
      Click to Submit by Email
                          -- Please attach any additional  supporting documents and  send securely from your email .
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