MEMBERSHIP REGISTRATION FORM

 

Your Name:                             ________________________________________________

 

Your Position:                           ________________________________________________

 

Organization Name:                  ________________________________________________

 

Number of Employees:             ________________________________________________

 

Street Address:                         ________________________________________________

 

City, State, ZIP, Country:         ________________________________________________

 

                                                    ________________________________________________

 

Business Telephone:                  ________________________________________________

 

E-Mail Address:                       ________________________________________________

 

I was referred to CIS by

someone from the

following CIS Member

Organization or Individual

Member:                                  ________________________________________________

 

Other:                                      ________________________________________________

 

           

 

 

Please check the level of Annual Membership for which youqualify:

 

______  $20,000– Security Software Company (CIS Certification Member)

 

______  $14,000– Consultant, Auditor, Software Company

 

______  $  9,000 – Large User Organization(100 employees or more)

 

_______  $4,500– EDUCAUSE Institutional Members (50% discount off of Large User

                              Organization membership fee)

 

______  $  2,500 – Small User Organization(fewer than 100 employees)

 

______  $     300 –Individual**

 

______  **Please initial here – In applying forindividual membership, I certify that I am not affiliated with an organization,or that my organization will not reimburse me for the membership fee.  I acknowledge that as an IndividualMember, I am not eligible to distribute the CIS Benchmarks and/or Scoring Toolswithin my organization. 

 

For new members, the membership fee covers a one yearperiod beginning upon receipt of this application and payment of the membershipfee.  For renewing members, themembership fee extends the term of the renewing member’s current membership byone full year.

 

_____ – New Membership Enrollment (check here)

 

_____ – Renewing Member (check here)

 

Please indicate method of payment:

 

______  Check(enclosed with this form)

 

______  VISA

 

______  MC

 

______ AmericanExpress

 

______  Wire/EFT (Payment of the CIS Membership Fee may be made by wire transfer or Electronic Funds Transfer (EFT). If your organization wishes to process payment by this method, pleasecontact Steve Kreitner at skreitner@cisecurity.org for the CIS Banking information.)

 

 

Card Number: _______________________________________________

 

Expiration Dater: _____/______

 

Name as it appears on Credit Card: _______________________________________________

 

Telephone Number of Card Holder: _______________________________________________

 

Please provide your comments or suggestions: ________________________________________