HSIA -- Membership Application

HSIA

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Policy Forums

1.	Airport Security
2.	Port/Maritime Security
3.	Bioterrorism/Chemical & Nuclear Security
4.	Physical Security/Critical Infrastructure Protection
5.	Information Security
6.	Food Supply/Distributuin Security
7.	Information Sharing Technology
8.	Best Business Practices

Membership Application

I hereby apply for membership in HSIA.

(Please Check the appropriate category):

Corporate Member	Board of Advisors	Affiliate Member
Individual	Academic	Student

Company/Individual Name:
Street Address:
City/State, Zip:	/,
Phone:	(ex. 000-000-0000)
Fax:	(ex. 000-000-0000)
Email:
Brief Company/ Business Description:
The Company is Public and is traded on the exchange as
The Company is Private. Please keep our revenues confidential: Yes No
Our worldwide revenues for the four most recent fiscal quarters ending in (month/year): were: $ (Your annual HSIA membership dues are based on your total gross revenue from all activities of your company. Please see dues schedule for calculations.)
Our Check in the amount of US $ will be mailed.* *Alternatively, funds may be wired to the account of HSIA at First Union Bank, Washington, D.C. bank, routing #054001220; and account #2030000089646. Please invoice us.

Contact person to receive all HSIA mailings:
Name:
Title:
Phone:	(ex. 000-000-0000)
Fax:	(ex. 000-000-0000)
Email:
Date
CEO Contact Information (if not provided above) - To Be Held In Confidence by
Name:
Title:
Phone:	(ex. 000-000-0000)
Fax:	(ex. 000-000-0000)
Email:

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