Personal Information

To which chapter do you wish to belong?

Preferred Mailing Address:

First name:

Middle name:

Last name:

Business Information

Business title:

Company:

Street address:

City:

State/Province:

Zip/Postal Code:

Country:

Business phone:

Business fax:

Email Address:

Home Information

Street address:

City:

State/province

Zip/postal code:

Country:

Home phone:

Employment - Current Position

Full-time Part-time

Present Employer:

Job Title:

Date Employed: (month/year)

Description of security duties and responsibilities:

Eligibility Information

Have you ever been convicted of a crime (or in military service convicted by a general court martial) or is there any criminal charge now pending against you?
Yes No

Have you ever had a professional membership, license, registration, or certification denied, suspended, or revoked (other than a lack of minimum qualification or failure of examination)?
Yes No

Have you ever been censured or disciplined by any professional body or organization?
Yes No

If the answer to one or more of these questions is "Yes", please explain below. This information will not be circulated outside the ASIS International Board of Directors or its chief executive officer.

Applicant must not have been convicted of any criminal offense that would reflect negatively on the security profession and ASIS International.

New Member Dues
Member/Associate Fees - $170

Statement and Signature

I certify that all information herein is true and complete to the best of my knowledge and belief. I authorize verification of this information, and release all concerned from any liability in connection therewith. I hereby apply for membership in ASIS International and have read and understand the qualifications of membership, applications fees, and dues payment requirements. I agree to abide by ASIS International's bylaws, agree to adhere to its code of ethics, and to promote its objectives. Providing false or misleading information in this application form or failure to adhere to ASIS bylaws and code of ethics shall be grounds for denial of membership or expulsion from ASIS International whenever discovered.

Enter your initials here, to serve as your signature