Page 9 - NCISS Privacy Special Report (March 2019)

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: nciss1976@yahoo.com Download this application at
www.nciss.org/application-membership
MEMBER INFORMATION
Name:
Company:
Address:
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 $_____________
REFERENCES
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:

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