ASSOCIATE MEMBER APPLICATION FORM

INSTITUTE FOR INTERNAL CONTROLS IIC ASSOCIATE MEMBER APPLICATION FORM

109 Mullen Drive, Sicklerville, NJ 08081 USA
INSTRUCTIONS

ASSOCIATE MEMBER PROGRAM IS NOT AVAILABLE IN ALL COUNTRIES BASED ON AVAILABILITY OF CERTIFICATION VIA EXAM OR VIA CURRICULUM PROGRAMS. EMAIL chairman@theiic.org TO DETERMINE YOUR ELIGIBILITY OR STATUS OF PROGRAMS IN YOUR COUNTRY. An Associate Member is a non-certified member of the IIC who typically is studying for or registered to take the CICA or CCS Certification Examination or enrolled in the Certification via Curriculum Program or a Full-time Student in one of the approved Special Masters Programs. Associate Members have access to all benefits of Full Certified Members, but may not use the CICA or CCS designation. Associate Members must renew their membership annually until they complete the applicable certification program. Members are encouraged to provide both a primary e-mail and a secondary/alternative e-mail in the application in case of email problems. For future changes in your profile please complete the Member Change Request form available on TheIIC website.
For your convenience, Autofill will keep all your input data for 24 hours if you must leave the form before completing. You must use the same browser in order to pick up the form where you left off!
Declaration of Understanding: *

I have read, understand and will abide by the application instructions. I do not understand the instructions for this application and will not become a member.
Associate Member Fees

Application Fee- $25.00 + Annual Membership Fee-$50.00 (TOTAL $75.00)

Note: Annual Associate Member Renewal Fee is $50.00

Complete all required information below

* denotes a required field that must be completed in order to process the application.
Personal Information
Associate Program Applied for: *
Application Date *

Month Day Year
Salutation: *
First Name *
Middle Name
Last Name *
Primary Mailing Address *

Street Address

P.O. Box or Suite (if any)

City State

Postal/ZipCode (If you are applying from a country that does not utilize postal codes or zip codes, TYPE N/A or NONE. This field is not for PO Boxes) Country
PRIMARY Phone # *

Country Code Area Code Phone Number
Phone Type
ALTERNATE Phone #

Country Code Area Code Phone Number
Phone Type
PRIMARY e-MAIL *
e-Mail Type
SECONDARY e-MAIL
e-Mail Type

Qualifications
Academic Institution Attended (if any)
Academic Credentials Earned
Employer (if any)
Position (if any)
Please include anything you wish to add to your application here (Limit 100 words)

0/100
Have you ever been convicted of a felony? *

Yes No
If Yes, explain below (Limit 100 words)

0/100

Applicant's Declaration

Check the boxes below to affirm each statement
Check each to affirm: *

*I declare that all of the information contained in this application is true and correct and agree to provide any supporting documentation requested by the Nominations Committee. *If accepted, I agree to abide by the IIC's Code of Ethics and Code of Professional Standards *I understand that I must renew my membership annually and be a member in good standing in order to retain my Associate Member Status *I understand that Associate Membership DOES NOT allow me to hold myself out as a CICA or CCS. *I understand that I must register for the Certification via Examination Program or Certification via Curriculum Program within 60 days of notice of grant of Associate Membership.

Applicant's Electronic Signature

WARNING: UNSIGNED APPLICATIONS WILL BE REJECTED!
Type your name followed by /es/ into the box *

Checklist

Check off all boxes below to confirm that you have completed all portions of the application.
Application Checklist *

Read Application instructions page and complied with instructions Signed the Application Ready to Submit Application and Pay

Fees (Note: Payment required with application)

Fees effective January 1, 2017

Associate application fee + annual membership fee: $75.00

Make check or money order payable to The Institute for Internal Controls, Inc. (Federal TIN: 16-1783223)

*Registration fees cover a 12-month period, commencing with the month your application is approved.*

Annual Membership fees are billed annually and are due on the anniversary of your application approval.

NOTE: You MUST click the PRINT button on the “Submit and Pay” tab to provide a hardcopy of this form. You may not be able to print out a copy of the form for your records once you click the SUBMIT button.

Method of Payment *

Credit Card Check or Money Order to be sent by applicant Check or Money Order to be sent by applicant's employer Payment Made directly to IIC country representatives (Pakistan, Greece, Philippines ONLY)
If you chose to pay your membership fees via 2 Checkout, you must email membership@theiic.org for a link that will take you to the product page on 2Checkout where you can pay the required fees. No action on your application will be considered before receipt of payment in full.
If paying by Check or Money Order, click the submit button to send your completed application to the IIC. Send your Check or Money Order in the full amount:

Institute for Internal Controls
Attn: Nominations Committee
109 Mullen Drive
Sicklerville, NJ 08081
USA
Should be Empty:

INSTITUTE FOR INTERNAL CONTROLS IIC ASSOCIATE MEMBER APPLICATION FORM

INSTRUCTIONS

Associate Member Fees

Application Fee- $25.00 + Annual Membership Fee-$50.00 (TOTAL $75.00)

Complete all required information below

Personal Information

Qualifications

Applicant's Declaration

Checklist