10/07956/GD/JP Return application to: The Institute of Internal Auditors P.O. Box 281196, Atlanta, GA 30384-1196 USA Fax: +1-407-937-1101 IIA MEMBERSHIP APPLICATION (Please print clearly.) Name:________________________________________________________________Gender:_ _____________Date_of_Birth_(MM/DD):___________ Job_Title:_____________________________________________________________ Are_you_a:_ p_CIA_ p_CCSA_ p_CGAP_ p_CFSA Organization:_____________________________________________________________________________________________________________ Business_Address:_ _________________________________________________________________________________________________________ Business_Phone:________________________________________________ _Business_Fax:_ ______________________________________________ E-mail_Address: ________________________________________________ _Home_Phone:_ ______________________________________________ Home_Address:____________________________________________________________________________________________________________ Chapter_Affiliation_Desired_(for_a_chapter_list_go_to_www.theiia.org/membership):_ _______________________________________________________ Job_Code_(for_a_job_code_list,_refer_to_second_page):__________________Industry_Code_(for_an_industry_list,_refer_to_second_page): _______________ Preferred_Mailing_Address:_ p_Business_ p_Home_ Preferred_Telephone_Number:_ p_Business_ p_Home Have_you_ever_been_convicted_of_a_felony?_ p_ Yes_ p_ No I declare that: 1._ All_information_contained_on_this_application_is_true_and_correct._ 2._ If_accepted,_I_agree_to_abide_by_the_Code_of_Ethics_adopted_by__ _ The_Institute_of_Internal_Auditors_to_govern_its_members. Applicant_Signature:_ __________________________________________________________________ Date:________________________________ E-MAIL COMMUNICATIONS FROM THE IIA AND YOUR LOCAL CHAPTER/INSTITUTE p_ Please_DO NOT_send_me_any_e-mails_related_to_member_benefits._Member_benefit_e-mails_include_but_are_not_limited_to_newsletters,_research_reports,__ benchmarking_surveys,_publication_announcements,_IIA_guidance_and_news,_and_international_committee_meeting_notices._If you check this box you will receive NO IIA communications transmitted by e-mail regarding member benefits. p_ Please_DO NOT_send_me_any_e-mails_related_to_discounts,_special_promotions,_and_other_offers._Offers_include_e-mails_on_IIA_certification_programs,__ seminars,_conferences,_and_book_offers. MANY OF OUR CHAPTERS, INSTITUTES, AND PARTNERS ARE INTERESTED IN COMMUNICATING WITH YOU. WITH THAT IN MIND, PLEASE LET US KNOW YOUR PREFERENCES. p_ Please_DO NOT_include_my_contact_information_in_IIA_and_local_chapter_member_directories. p_ Please_DO NOT_use_my_contact_information_for_non-IIA_mailings. _ _ Application_Fee_ $_ ____________________________________________ _ Membership_Dues_ $_ ____________________________________________ For checks drawn on banks outside the US and Canada add US $30 bank collection charge. _ Specialty_Membership_ $_ ____________________________________________ _ Total_Amount_ $_ ____________________________________________ Check One: p_ Check_enclosed_(payable_to_The_Institute_of_Internal_Auditors) p_ Charge_my_credit_card_ p_ AMEX_ p_ _VISA_ p_ MasterCard Card_No._ __________________________________ __Expiration_Date_ _________ Card_Holder_Name__ _________________________________________________ Signature__ _________________________________________________________ PAYMENT INFORMATION (US DOLLARS): Application fee of US $25 (does not apply with Educational, Student, or Government Membership) and appropriate dues for year of admittance must accompany this application. Dues are billed yearly on the anniversary date of membership. Dues are tax deductible (US members). Annual membership dues include a US $40 fee for Internal Auditor, a US $10 fee for IIA Insight, and a US $5 fee to other professional publications. These fees cannot be deducted from the dues. MEMBERSHIP CLASSIFICATION: Application Fee Total Due p_ IIA_member__ US_$130_ US_$25_ US_$155 p_ Educational_member__ US_$65_ n/a_ US_$65 p_ Student_member__ US_$30_ n/a_ US_$30 p_ Government_member__ US_$65_ n/a_ US_$65 SPECIALTY MEMBERSHIP SECTIONS: (Additional Fees) p_ Chief_Audit_Executive_Services_Program_(US_$100)_ p_ Financial_Services_Auditor_Group_(US_$40)_ p_ Gaming_Audit_Group_(US_$40)_ RM RESET THIS FORM
Transcript
1007956GDJP
Return application to The Institute of Internal Auditors PO Box 281196 Atlanta GA 30384-1196 USA Fax +1-407-937-1101
Have_you_ever_been_convicted_of_a_felony_ p_ Yes_ p_ No
I declare that 1_ All_information_contained_on_this_application_is_true_and_correct_2_ If_accepted_I_agree_to_abide_by_the_Code_of_Ethics_adopted_by___ The_Institute_of_Internal_Auditors_to_govern_its_members
E-MAIl coMMunIcAtIonS fRoM tHE IIA And youR locAl cHAPtERInStItutE
p_ Please_DO NOT_send_me_any_e-mails_related_to_member_benefits_Member_benefit_e-mails_include_but_are_not_limited_to_newsletters_research_reports__benchmarking_surveys_publication_announcements_IIA_guidance_and_news_and_international_committee_meeting_notices_If you check this box you will receive NO IIA communications transmitted by e-mail regarding member benefits
PAyMEnt InfoRMAtIon (uS dollARS) Application fee of US $25 (does not apply with Educational Student or Government Membership) and appropriate dues for year of admittance must accompany this application Dues are billed yearly on the anniversary date of membership Dues are tax deductible (US members)
Annual membership dues include a US $40 fee for Internal Auditor a US $10 fee for IIA Insight and a US $5 fee to other professional publications These fees cannot be deducted from the dues
MEMBERSHIP clASSIfIcAtIon Application Fee Total Due
245 IT Audit Director mdash_I_am_head_of_the_IT_audit_activity_within_my_organization
250 IT Audit Manager mdash_I_administer_the_IT_audit_activity_of_an__assigned_location_within_the_general_guidelines_provided_by_the_director__of_auditing
260 IT Audit Staff mdash_I_conduct_or_assist_in_conducting_reviews_of__assigned_organizational_and_functional_activities_related_to_IT_auditing
245 IT Audit Director mdash_I_am_head_of_the_IT_audit_activity_within_my_organization
250 IT Audit Manager mdash_I_administer_the_IT_audit_activity_of_an__assigned_location_within_the_general_guidelines_provided_by_the_director__of_auditing
260 IT Audit Staff mdash_I_conduct_or_assist_in_conducting_reviews_of__assigned_organizational_and_functional_activities_related_to_IT_auditing
