Membership Application - Credential Integrity Action Alliance

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Your Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Renewing Membership?(Required)

Select Yes if you are currently a member.

Yes

No

Other

If other:

Organization Information

Name

Your Title(Required)

Type of Organization(Required)

For Profit

Non-profit

Individual Friend

Website

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Secondary Contact at Organization(Required)

If you are applying as an "Individual Friend", please enter "N/A" in the space provided.

Full Name

Secondary Contact Email

Membership Level & Pledge

Membership Level(Required)

Sustaining (For Profit Orgs -$16,000 minimum; Non-Profit Orgs - $10,000 minimum)

Supporting (For Profit Orgs -$10,000 minimum; Non-Profit Orgs - $7,000 minimum)

Friend (Non-profit - $500 minimum; Individual - $100 minimum)

Pledge Amount(Required)

Due 60 days within your membership approval.

Invoice Details

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Additional Invoice Instructions

Agreement & Attestation

By agreeing and submitting this form, I allow CIAA to recognize this organization as a member in CIAA publications and materials, including the CIAA website.(Required)

If you are applying as an Individual – Friend, please select “N/A” from the options provided.

Yes, I agree

No, I prefer that this organization not be included

N/A - I am an Individual - Friend

By agreeing and submitting this form, I understand that CIAA membership does not begin until CIAA has received payment for the amount pledged.(Required)

Yes, I agree

By completing and submitting this application and pledge form, I attest that the prospective member organization (inclusive of its leadership) and individual named within this application do not participate in the commercial exploitation of assessment programs, or have a material financial interest in, or otherwise receive compensation or benefits from, companies that offer cheating services.(Required)

Yes, I attest

No, I decline

Electronic Signature(Required)

Please type in full name.

Today's Date(Required)

MM slash DD slash YYYY

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