iia membership application rm10/07956/gd/jp return application to: the institute of internal...
TRANSCRIPT
1007956GDJP
Return application to The Institute of Internal Auditors PO Box 281196 Atlanta GA 30384-1196 USA Fax +1-407-937-1101
IIA MEMBERSHIP APPlIcAtIon(Please print clearly)
Name________________________________________________________________Gender_ _____________Date_of_Birth_(MMDD)____________
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_wwwtheiiaorgmembership)________________________________________________________
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 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
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_ na_ US_$65
p_ Student_member__ US_$30_ na_ US_$30
p_ Government_member__ US_$65_ na_ 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
200 Chief Audit Executive mdash_I_am_the_most_senior_audit_officer_for_the_organization_and_have_ultimate_responsibility_for_the_entire_internal_audit_function
210 Director of Audit mdash_I_am_the_chief_auditor_authorized_to_direct_a_broad_comprehensive_program_of_internal_auditing_within_my_organiza-tion
220 Audit Manager mdash_I_administer_the_internal_audit_activity_of_an_assigned_location_within_the_general_guidelines_provided_by_the_director_of_auditing
230 Audit Staff mdash_I_conduct_or_assist_in_conducting_reviews_of__assigned_organizational_and_functional_activities
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
275 Audit Services Contractor mdash_I_offer_internal_audit_services_on_a_contracted_basis
280 External Public Accountant mdash_I_am_a_practicing_public__accountant_chartered_accountant_etc
300 Corporate Management mdash_I_am_a_corporate_officer_(chief_finan-cial_officer_chief_information_officer_or_chief_executive_officer)_and_do_not_qualify_under_another_job_code_above
310 Educator mdash_I_am_principally_employed_as_an_educator_at_a_college_or_university_(PhD_DBA_EdD_etc)
320 Student mdash_I_am_pursuing_a_degreed_program_at_a_college_or__university_(including_doctoral_candidates)_on_a_full-time_basis
330 Retired mdash_I_am_retired_from_active_employment_(otherwise_refer_to_another_job_code)
340 Audit Committee Member mdash_I_am_an_audit_committee_member__of_a_corporate_board_of_directors_(and_do_not_qualify_under_another_job_code_above)
350 Management Consultant mdash_I_am_primarily_an_independent__consultant_with_an_interest_in_internal_auditing_(otherwise_refer_to_another_job_code)
360 Other mdash_Specify_title_or_job_description
Job codes Select_the_position_that_best_describes_your_role_and_function_(not_necessarily_your_exact_title)_in_your_organization__Enter_the_appropriate_number_in_the_job_code_section_of_the_application
Industry codesAgriculture forestry and fisheries
0100_ Agricultural_forestry___fisheries_production_services
Mining
1000_ Mining1300_ Oil_and_gas_extraction
contract construction
1500_ Construction
Manufacturing
2000_ Foodkindred_products2100_ Tobacco_manufacturers2200_ Textile_mill__
productsapparel2400_ Lumberwood_products_
(incl_furniturefixtures)2600_ Paper_and_allied_products_
(incl_printingpublishing)2800_ Chemicals2830_ Drugs_and_research2840_ Petroleum_refining__ _
and_related_industries3010_ Rubber_and_plastics_
products3100_ Leather_stone_and__ _
glass_products3300_ Primary_metal_industries3400__ Fabricated_metal__
products_(including__ _nonelectric_machinery)
3500_ Industrial_and_commercial_machinery
3510_ Aerospace3520_ Computers_and_related_
devicesequipment3600_ Electrical_machinery__
electronic_equipment__and_supplies
3700_ Transportation_equipment3800_ Scientific_photographic_
medical_goods3900_ Miscellaneous__
manufacturing_industries
transportation communications and utility Services
4000_ Land_transportation4400_ Water_transportation4500_ Air_transportation4700_ Other_transportation__
services4800_ Communication_services4810_ Telecommunications4900_ Electricgassanitary__ _
services4910_ Gas_services4920_ Gas_amp_electric_services4930_ Sanitary_services
wholesale and Retail trade
5000_ Wholesale_trade5300_ Retail_trade5800_ Eating_and_drinking_places
financial Insurance and Real Estate
6000_ Banking_and_financial__institutions
6030_ Nonbanking_bank__ _services_(eg_leasing)
6040_ Thrift_and_savings_and__loan_organizations
6100_ Credit_unions6130_ Other_credit_agencies6200_ Security_and_
commodity_services6300_ Insurance_carriers__ _
agents_services6500_ Real_estate_services6700_ Holdinginvestment__ _
companies
Services
7000_ Hotelslodging__services
7200_ Personalsocial_services7300_ Contracted_audit_services7310_ Management_consultants7320_ Information_technology_
services7330_ Executive_placement___
services7500_ Repair_services7600_ Gaminglottery7800_ Motion_pictures_
amusement_and__recreational_services
8000__ Health_services8100_ Legal_services8200_ Educational_services8600_ Membership_organizations8900__ Public_accounting_
accountingbookkeeping_services
8910_ Miscellaneous_services
government
9100_ Federalnational__government
9200_ Stateprovincial_government
9300_ Local_government9400_ International_government
nonclassifiable
9900_ Nonclassifiable__ _establishments
- Name
- Job Title
- Organization
- Business Address
- Business Phone
- Business Fax
- E-mail Address
- Home Phone
- Home Address
- Gender
- Date of Birth
- CIA Off
- CCSA Off
- CGAP Off
- CFSA Off
- Chapter Affiliation
- Job Code
- Industry Code
- Preferred Mailing Address Business
- Preferred Telephone Number Business
- Chief Audit Executive Services Program Off
- Financial Services Auditor Group Off
- Gaming Audit Group Off
- Felony Conviction Off
- Applicant Signature Date
- Check Enclosed Off
- Charge my credit card Off
- Credit Card Number
- Expiration Date
- Credit Card Type Off
- Credit Card Holder Name
- No Member Benefit Emails Off
- No Discount Emails Off
- No IIA Contact Info Off
- No Non-IIA Contact Info Off
- Button5
- ApplicationFee
- MembershipFee
- AdditionalFee 0
- TotalAmount
- Membership Off
200 Chief Audit Executive mdash_I_am_the_most_senior_audit_officer_for_the_organization_and_have_ultimate_responsibility_for_the_entire_internal_audit_function
210 Director of Audit mdash_I_am_the_chief_auditor_authorized_to_direct_a_broad_comprehensive_program_of_internal_auditing_within_my_organiza-tion
220 Audit Manager mdash_I_administer_the_internal_audit_activity_of_an_assigned_location_within_the_general_guidelines_provided_by_the_director_of_auditing
230 Audit Staff mdash_I_conduct_or_assist_in_conducting_reviews_of__assigned_organizational_and_functional_activities
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
275 Audit Services Contractor mdash_I_offer_internal_audit_services_on_a_contracted_basis
280 External Public Accountant mdash_I_am_a_practicing_public__accountant_chartered_accountant_etc
300 Corporate Management mdash_I_am_a_corporate_officer_(chief_finan-cial_officer_chief_information_officer_or_chief_executive_officer)_and_do_not_qualify_under_another_job_code_above
310 Educator mdash_I_am_principally_employed_as_an_educator_at_a_college_or_university_(PhD_DBA_EdD_etc)
320 Student mdash_I_am_pursuing_a_degreed_program_at_a_college_or__university_(including_doctoral_candidates)_on_a_full-time_basis
330 Retired mdash_I_am_retired_from_active_employment_(otherwise_refer_to_another_job_code)
340 Audit Committee Member mdash_I_am_an_audit_committee_member__of_a_corporate_board_of_directors_(and_do_not_qualify_under_another_job_code_above)
350 Management Consultant mdash_I_am_primarily_an_independent__consultant_with_an_interest_in_internal_auditing_(otherwise_refer_to_another_job_code)
360 Other mdash_Specify_title_or_job_description
Job codes Select_the_position_that_best_describes_your_role_and_function_(not_necessarily_your_exact_title)_in_your_organization__Enter_the_appropriate_number_in_the_job_code_section_of_the_application
Industry codesAgriculture forestry and fisheries
0100_ Agricultural_forestry___fisheries_production_services
Mining
1000_ Mining1300_ Oil_and_gas_extraction
contract construction
1500_ Construction
Manufacturing
2000_ Foodkindred_products2100_ Tobacco_manufacturers2200_ Textile_mill__
productsapparel2400_ Lumberwood_products_
(incl_furniturefixtures)2600_ Paper_and_allied_products_
(incl_printingpublishing)2800_ Chemicals2830_ Drugs_and_research2840_ Petroleum_refining__ _
and_related_industries3010_ Rubber_and_plastics_
products3100_ Leather_stone_and__ _
glass_products3300_ Primary_metal_industries3400__ Fabricated_metal__
products_(including__ _nonelectric_machinery)
3500_ Industrial_and_commercial_machinery
3510_ Aerospace3520_ Computers_and_related_
devicesequipment3600_ Electrical_machinery__
electronic_equipment__and_supplies
3700_ Transportation_equipment3800_ Scientific_photographic_
medical_goods3900_ Miscellaneous__
manufacturing_industries
transportation communications and utility Services
4000_ Land_transportation4400_ Water_transportation4500_ Air_transportation4700_ Other_transportation__
services4800_ Communication_services4810_ Telecommunications4900_ Electricgassanitary__ _
services4910_ Gas_services4920_ Gas_amp_electric_services4930_ Sanitary_services
wholesale and Retail trade
5000_ Wholesale_trade5300_ Retail_trade5800_ Eating_and_drinking_places
financial Insurance and Real Estate
6000_ Banking_and_financial__institutions
6030_ Nonbanking_bank__ _services_(eg_leasing)
6040_ Thrift_and_savings_and__loan_organizations
6100_ Credit_unions6130_ Other_credit_agencies6200_ Security_and_
commodity_services6300_ Insurance_carriers__ _
agents_services6500_ Real_estate_services6700_ Holdinginvestment__ _
companies
Services
7000_ Hotelslodging__services
7200_ Personalsocial_services7300_ Contracted_audit_services7310_ Management_consultants7320_ Information_technology_
services7330_ Executive_placement___
services7500_ Repair_services7600_ Gaminglottery7800_ Motion_pictures_
amusement_and__recreational_services
8000__ Health_services8100_ Legal_services8200_ Educational_services8600_ Membership_organizations8900__ Public_accounting_
accountingbookkeeping_services
8910_ Miscellaneous_services
government
9100_ Federalnational__government
9200_ Stateprovincial_government
9300_ Local_government9400_ International_government
nonclassifiable
9900_ Nonclassifiable__ _establishments
- Name
- Job Title
- Organization
- Business Address
- Business Phone
- Business Fax
- E-mail Address
- Home Phone
- Home Address
- Gender
- Date of Birth
- CIA Off
- CCSA Off
- CGAP Off
- CFSA Off
- Chapter Affiliation
- Job Code
- Industry Code
- Preferred Mailing Address Business
- Preferred Telephone Number Business
- Chief Audit Executive Services Program Off
- Financial Services Auditor Group Off
- Gaming Audit Group Off
- Felony Conviction Off
- Applicant Signature Date
- Check Enclosed Off
- Charge my credit card Off
- Credit Card Number
- Expiration Date
- Credit Card Type Off
- Credit Card Holder Name
- No Member Benefit Emails Off
- No Discount Emails Off
- No IIA Contact Info Off
- No Non-IIA Contact Info Off
- Button5
- ApplicationFee
- MembershipFee
- AdditionalFee 0
- TotalAmount
- Membership Off