Last Name:

  First: Middle:

Title:

Institution/Agency:

 Street Address:

City:

State: Zip:

Work Phone:

Home: Fax:

E-Mail:

EMPLOYMENT

Current Employer:

Title:

  How Long?:yrs.

Street Address:

City:

State: Zip:

Duties:

Previous Employer:

Title:

Street Address:

City:

State: Zip:

Have you ever been convicted for a crime other than a misdemeanor, traffic violation in the last (7) years?

Yes:         No:

If Yes, Please Explain:

EDUCATION

Institution:

Degree Obtained:

  Date:

City:

State: Country:

List your area of expertise/specialty:

Are you bilingual?

Yes:         No:

Language:     Read:     Write:

Language:     Read:     Write:

Language:     Read:     Write:

Certifications?

Yes:         No:

Certification: Date Awarded:

Certification: Date Awarded:

Certification: Date Awarded:

If applying for student membership, please complete the following:

Major: Expected Date of Graduation:

PROFESSIONAL MEMBERSHIP

Are you member of the American Society for Industrial Security?

Yes:  No:

Membership#:

Are you Certified Protection Professional?:     Yes:      No:

SCHOLARSHIP FUND

Scholarship contributions help build the scholarship funds for deserving students.  IOBSE conducts educational workshops at a designated college annually.  Your contribution may be tax deductible and will be used solely for scholarships.

*Upon submitting this form you will be re-directed to a form that you can fill in with your payment information, print out, and either fax or send in the mail. Please mail completed payment information to:

IOBSE

P.O. Box 1471

San Mateo, CA 94401

Toll Free 1-888-884-6273

www.iobse.com

or Fax to:

1-630-236-3629

MEMBERSHIP DUES

Annual dues payment covers one calendar year.  Membership expires on December 31st of each year.  Applications accepted prior to September 1 of each year, membership will expire on December 31 of same year.  Applications accepted after September 1 of each year, membership will be good until December 31 of the following year.

CERTIFICATION

I hereby certify that the above statements are true to the best of my knowledge and are made in good faith.  Any omission of information or false statements made by me on this application constitutes grounds for dismissal of membership once accepted.  By submitting this form, I agree to abide by the By-Laws and Policy & Procedure guidelines of the IOBSE, and will act in a professional manner when representing the organization.