Form UnNumbered InfraGard Membership Application

OMB No. 1110-0049

InfraGard Domestic Membership Application
Name (Applicant) :
Employer:
Title:
Business Address1:
City:

State:

Zip Code:
Home Address1:
City:

State:

Zip Code:
Chapter Selection

State: Select State

City:

Email Address:
Fax:

Phone:
Date of Birth:

U.S. Citizen:

City, County, State, and Country of birth:
Social Security Number:
Code Word:

Yes

No

Driver's License Number:

2

Have you ever been arrested for, charged with, or convicted of a felony or non-traffic misdemeanor?
If yes, please attach an explanation of the occurrence(s) making sure to include dates, agencies involved, case
numbers, disposition, and any additional information that you feel would assist us in making a membership decision
(Check one):
No
Yes (Number of pages attached:
)
Do you currently possess a Qualifying Substitute for the records check required for InfraGard Membership? (A
current list of Qualifying Substitutes is available in a separate document or on the InfraGard web site):
No
Yes, I am an InfraGard SAA Member and already successfully completed a records check
(InfraGard Chapter:
Application Date: 3
)
Yes, I posses a current and valid Security Clearance listed as a Qualifying Substitute
Expiration:
(Clearance:
Issuing Agency:
(Security Contact:
Which Critical Infrastructures is your organization a part of? Check all that apply:
Chemical Industry &
Agriculture
Banking & Finance
HAZMAT
Emergency Services
Defense
Energy
Government
Information & Telecom.
Food
National Monuments &
Law Enforcement
Postal & Shipping
Icons
Water
Transportation
Public Health
Other:
1

Physical street address required. No PO boxes.
Authentication for Help Desk use. Examples include mother's maiden name, city of birth, etc…
3
If exact date is unknown, please provide an approximate date
2

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)
)

If accepted as a member of InfraGard, Applicant may receive information that is sensitive and not publicly available
(“Protected Information”). Protected Information may be provided by or through the InfraGard National
Organization, InfraGard chapters, InfraGard members, partners of InfraGard, or other sources, and will be marked
:
accordingly. If accepted as an InfraGard member, Applicant understands and agrees to the following terms
regarding Protected Information
1.

Participation is Voluntary. Applicant is not obligated as a condition of InfraGard membership to disclose
any information to the InfraGard National Organization or any InfraGard chapter, partner, or member.

2.

Confidentiality and Non-Disclosure. Protected Information is to be regarded as Business Confidential
and shall not be disclosed beyond its intended scope.

3.

No guarantee of fitness. Protected Information is provided as a service to InfraGard members and may be
unevaluated and unverified. As such Protected Information is not guaranteed to be accurate, complete, or
actionable.

4.

Submission in Good Faith. Applicant agrees that it will not submit information which it knows at the
time of submission to be false, and that it will submit information only to further InfraGard’s stated
purposes.
Federal Agencies will exercise care to protect information. To the extent allowed by law, information
received from InfraGard members that is marked “InfraGard Protected Information” shall be protected
from agency disclosure under 5 USC §552 (commonly referred to as the Freedom of Information Act
(“FOIA”)), and from publication, divulgence, or release in any other manner pursuant to the prohibitions of
the Trade Secrets Act, 18 USC §1905.

5.

Applicant understands and agrees that InfraGard is not to be commercially exploited as a forum to market products
or services and that doing so may result in the revocation of Applicant’s membership in InfraGard.
Applicant, if accepted as an InfraGard member, agrees to act in a manner consistent with the InfraGard National ByLaws, as the ByLaws may be amended from time to time, as well as any other duly enacted national requirements of
InfraGard.
Applicant requirements:
• US Citizen by birth as defined by 8 USC §1401-§1409, OR US Citizen by Naturalization
as defined by 8 USC §1421-§1459;
• Over 18 years of age on the date of completion of this Application;
• Consent to a records check that yields a satisfactory result as determined by the FBI in its sole discretion,
OR posses a Qualifying Substitute;
• Consent to periodic re-confirmation of membership requirements;
• Have sponsorship from an existing InfraGard member, chapter, or partner organization;
• Agree to and complete this InfraGard Membership Application Form;
• Any further requirements (if more restrictive) mandated by the local chapter and approved by the FBI.
Applicant acknowledges that their affiliation with InfraGard may be disclosed by InfraGard to another InfraGard
member, chapter, or partner. Applicant may choose to protect from public disclosure their affiliation with
InfraGard, and request that InfraGard and InfraGard Partners also protect from public disclosure the Applicant’s
affiliation with InfraGard to the full extent permitted by law.
May InfraGard publicly disclose Applicant’s association with InfraGard? (Check one):
No
Yes

Reset
InfraGard Domestic Membership Application

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PRIVACY ACT STATEMENT AND CONSENT

Authority:
Collection of this information is authorized under 28 CFR. § 0.85.
Principal Purpose and Routine Uses
The information collected on this form will be used for the principal purpose of conducting security risk assessments
on InfraGard Members and applicants. As part of this assessment, the collected data may also be used to assist in
determining approval, denial, revocation or renewal of access to the InfraGard Secure web site and the authorization
to receive InfraGard sensitive information. Information provided by me will be protected and used in strict compliance
with the Privacy Act and the routine uses most recently published in the Federal Register for the FBI's Central Records
System (Justice/FBI-002) and the FBI’s Blanket Routine Uses (Justice/FBI-BRU).
Social Security Account Number
Your Social Security Account Number (SSAN) is requested to check criminal, immigration, national security and
other electronic databases. Because other people may have the same name and birth date, your SSAN will be used
to facilitate accurate identification and to help eliminate the possibility of misidentification of individuals for whom
a security risk assessment or database check is being conducted.
Effects of Nondisclosure or Falsification
Completion of this application and provision of your SSAN is voluntary. However, failure to provide the requested
information may result in your application being rejected for membership in InfraGard or your membership revoked.
Knowingly falsifying or concealing information requested on this form will result in your application being rejected
or your membership revoked. In addition, Title 18 Section 1001 of the U.S. Code provides that knowingly
falsifying or concealing a material fact may under certain circumstances constitute a felony resulting in fines and/or
imprisonment.
Consent
By signing an InfraGard Membership Application Form, I hereby authorize the FBI to obtain and verify any information
relevant to assessing my suitability to access, possess, use, receive or transfer sensitive InfraGard Information. This
information may include, but is not limited to, law enforcement and intelligence information. I further authorize the
FBI to disclose information obtained in connection with my security risk assessment in order to verify the accuracy
or completeness of the information I have provided to the FBI. Other than to verify my information, I do not authorize
the FBI to disclose for the purpose of conducting my security risk assessment information provided by me on this form
absent my further written consent.
Paperwork Reduction Act Notice
The information required on this form is in accordance with the Paper Work Reduction Act of 1995. The purpose of
this information is to assist the FBI in security risk assessments for entities and individuals who are InfraGard
Members or applicants. The estimated average burden associated with this collection of information is 20 minutes,
depending on circumstances. Comments concerning the accuracy of this burden estimate and suggestions for
reducing this burden should be directed to Federal Bureau of Investigation, Records/Information Dissemination
Section, 935 Pennsylvania Ave., N.W., Washington, DC 920535.

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I understand that this is a legally binding document and false statements provided by me are violations of federal law
and may lead to criminal prosecution or other legal action. To the best of my knowledge and belief, I affirm that a).
I meet all of the requirements to be an InfraGard member; b). The information I have provided herein is true,
complete and correct; and c). I have reviewed the InfraGard Code of Ethics and I agree to abide by its covenants.

__________________________________________________________________ Date: _______________
PRINTED NAME
__________________________________________________________________ Date: _______________
SIGNATURE

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Below this Line for FBI Use Only

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Special Agent in Charge or Appointed Designee:______________________________________________________
Witness: ______________________________________________________________________________________

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Instructions for PDF submission
1. Complete the application (completely fill out all fields to avoid delays).
2. Print out the application
3. Sign and Date
4. Mail to:
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-----------------------------------------------------------------------------------------------------------------*If an address does not appear in the space above, please verify that you have selected
a chapter on PAGE 1.