Form UnNumbered InfraGard Application

INFRAGARD

1110-0049

INFRAGARD APPLICATION AND MEMBERSHIP AGREEMENTS

APPLICANT REQUIREMENTS
Applicant must be at least 18 years of age on the date of completion of this
Application.
Applicant must be a U.S. Citizen (U.S. Citizen by birth as defined by 8 USC
1401-1409 or a U.S. Citizen by Naturalization as defined by 8 USC 1421-1459).
Applicant must complete this InfraGard Membership Application Form in its
entirety.
Applicant must agree with the InfraGard Information Sharing Policy, Privacy Act
Statement, Agreements to Hold Harmless and Code of Ethics.
Applicant must consent to a security risk assessment and to periodic reconfirmation of the security risk assessment. The risk assessment is a
membership vetting process completed by the FBI which includes local, state,
and federal criminal history and driver’s license, citizenship, and other securityrelated database checks. Note that successful completion of the security risk
assessment does not equate to a security clearance (InfraGard members are not
given security clearances by the FBI).

InfraGard Application
Revised 01/16/2014

1

INFRAGARD MEMBERSHIP is for the owners, operators, and security directors and
their staffs of the 16 U.S. national key asset and critical infrastructure sectors, which
includes members of local, state, and federal law enforcement, as well as individuals
who are involved in the security of and protected research at educational institutions. A
description of the critical infrastructure sectors, and the disciplines included within each
one, can be found on the main InfraGard website. The 16 critical Infrastructure sectors
as set forth in Presidential Policy Directive (PPD)-21 are as follows:
Chemical

• Financial Services

Commercial Facilities

• Food and Agriculture

Communications

• Government Facilities

Critical Manufacturing

• Healthcare and Public Health

Dams

• Information Technology

Defense Industrial Base

• Nuclear Reactors, Materials and Waste

Emergency Services

• Transportation Systems

Energy

• Water and Wastewater Systems

The mission of InfraGard is to promote ongoing dialogue and timely communication
between members and the FBI specifically concerning the security of, vulnerabilities in,
and threats to critical infrastructure entities. InfraGard members are provided with
information to assist them in protecting critical infrastructure assets. In turn, they are
encouraged to provide information to the FBI, thereby facilitating its responsibilities to
detect, deter, and investigate acts of terrorism and other crimes. Because of the focus
and purpose of InfraGard, its members are required to be affiliated with at least one
critical infrastructure sector and, as part of the application process, applicants must pick
a primary affiliation sector.
INFRASTRUCTURE
With which critical infrastructure sector are you primarily affiliated? (mandatory
drop down – choose one)

InfraGard Application
Revised 01/16/2014

2

PERSONAL AND CONTACT INFORMATION
Full Name (Enter your official full name below, not a nickname.):
First Name (mandatory field)
Middle Name (If you do not have a middle name, enter NMN.) (mandatory field)
Last Name (If you are a “Jr.,” “Sr.,” etc. enter this here as well.) (mandatory field)
Home Address, City, State, Zip (mandatory fields)
Home Phone / Cell Phone (one phone number is required)
Home Email / Confirm Email (home or business email (below) must be provided)
DOB (mandatory field - provide required format mm-dd-yyyy – application should not
allow anyone to apply if they are not yet 18 years old.)
SSN (mandatory field – entry of 000-00-0000 or similar string should not be allowed)
POB (City/County (optional short field)/State (optional short field) /Country/Other
(optional short field))
DL#/State (both mandatory fields – DL field must allow for all types of special
characters)
CITIZENSHIP
Check the box that reflects your current citizenship status and provide the
applicable documentation:
I am a U.S. Citizen or national by birth in the U.S. or a U.S.
territory/commonwealth. Do one of the following:
Provide your U.S. Passport Number (Current): (optional short field)
o Expired (y/n)
o Date issued (mm/dd/yyyy)
Appear in person at the nearest FBI office, with a certified copy of your
birth certificate and a government photo ID, such as a driver’s license.
Contact your local InfraGard Coordinator to make an appointment.
I am a U.S. citizen or national by birth, born outside the U.S. Provide one of
the following:
InfraGard Application
Revised 01/16/2014

3

U.S. Passport Number (Current): (optional short field)
o Expired (y/n)
o Date issued (mm/dd/yyyy)
Document Number from State Department Form FS 240, DS 1350, FS 545,
etc.: (optional short fields for form type and number)
o Date form was completed (optional mm/dd/yyyy)
o Place of issuance (optional short field)
I am a naturalized U.S. citizen. Provide one of the following:
U.S. Passport Number (Current): (optional short field)
o Expired (y/n)
o Date issued (mm/dd/yyyy)
Citizenship Certificate Number (if applicable): (optional short field)
o Where was the citizenship certificate issued (City/Court/State)?
(optional short field)
o Date issued (optional mm/dd/yyyy)
Naturalization Certificate Number (if applicable): (optional short field)
o Where was the citizenship certificate issued (City/Court/State)?
(optional short field)
o Date issued (optional mm/dd/yyyy)

EMPLOYMENT
Employer
None (If none, skip to questions)
Employer Name (Mandatory field if “None” box is not checked. If self-employed, fill out
below contact information and self-employed section.)
Job Title (Mandatory field if “None” box is not checked)

InfraGard Application
Revised 01/16/2014

4

Employer Address, City, State, Zip (Mandatory field if “None” box is not checked)
Employer Website (optional field)
Business Phone / Cell (Mandatory if “None” box is not checked)
Business Email / Confirm Email (home (above) or business email must be provided)
Are you self-employed? (y/n) If you are self-employed, provide a short description of
the nature of your business, how it relates to a critical infrastructure, and your website
address (if you have one).
Are you retired? (y/n) If you are retired, provide the name of your last employer that
was related to a critical infrastructure, job title, city, state, and year of retirement.
Are you unemployed? (y/n) If you are unemployed, provide the name of your last
employer that was related to a critical infrastructure, job title, city, state and time of
employment (mm/yyyy-mm/yyyy)
Are you a student? (y/n) If you are a student, provide school name, address, city,
state, degree, area of study and how it relates to a critical infrastructure, and anticipated
graduation date.
MILITARY SERVICE
Have you EVER served in the US Military or US Merchant Marine? (y/n)
If “yes,” which branch and what were your dates of service? (optional short field)
Have you EVER received a discharge that was not honorable? (y/n)
o If “yes”, provide an explanation about the discharge, making sure to
include information that you feel would assist us in making a membership
decision. (paragraph field)
CRIMINAL HISTORY
Have you ever been arrested for, charged with, or convicted of a felony,
misdemeanor, Driving Under the Influence (DUI), or Driving While Intoxicated
(DWI)? Exclude minor parking and traffic violations such as parking and non-reckless
speeding tickets, but do not exclude reckless driving or other major moving violation
arrests, charges, or convictions. (y/n)
If “yes,” enter an explanation of the occurrence(s), making sure to include dates,
law enforcement agencies involved, and any additional information that you feel
would assist us in making a membership decision. (paragraph field)
InfraGard Application
Revised 01/16/2014

5

If you were in the military, have you been subject to court martial or disciplinary
proceedings under the Uniform Code of Military Justice? (y/n)
If “yes,” enter an explanation of the occurrence(s) making sure to include dates,
military branch of service and/or agencies involved, and any additional
information that you feel would assist us in making a membership decision.
(paragraph field)
Notice: If you check “no” for either of the above questions and the criminal history
check reveals information to the contrary, including DUI/DWI’s or records that you
thought had been expunged, such omission will be grounds for your application to be
automatically disqualified. You are not required to report arrests, charges, or
convictions that you believe to have been expunged. However, note that records you
believe to be expunged may not be, and/or they may still appear in your criminal history
without being listed as expunged. Please consider this in your responses, as apparent
omissions on your part will be grounds for your application to be automatically
disqualified (although you will have the opportunity to appeal a disqualification
determination).
Should I be approved as an InfraGard member, I agree to self-report any arrests,
charges, or convictions for criminal activity, including DUI/DWI incidents, while an
InfraGard member to the local FBI InfraGard Coordinator. I understand that minor
parking and traffic violations such as parking and non-reckless speeding tickets do not
need to be reported, but reckless driving or other major moving violations do need to be
reported.
CLEARANCE
Have you EVER had a Security Clearance? (y/n) If “yes,” what type of clearance
(Confidential, Secret, TS, etc.) and which agency issued it? (optional short field)
OTHER AFFILIATIONS
With what other professional, community or social organizations are you affiliated?
(optional paragraph field)
INFRAGARD CHAPTER
Choose Chapter (drop down)
Help Desk Code Word: The HELP desk will use your code word to authenticate you
when you contact the HELP desk. Examples include your mother’s maiden name, your
pet’s name, your city of birth, etc. (mandatory short field)

InfraGard Application
Revised 01/16/2014

6

Code Word Hint: This is a word or short statement that will help you remember
your Code Word. (mandatory short field)
Have you previously been a member of InfraGard? (y/n)
If “yes,” which Chapter(s) and time frame? (optional short field)
If “yes,” then skip next question.
Have you applied to InfraGard before? (y/n)
If “yes,” and you were not accepted for membership, what was the reason
provided for your not being accepted? (paragraph field)
How did you hear about InfraGard? Check all that apply. (drop down: Colleague,
Meeting Announcement, Presentation, Flyer, Other (include short field to describe what
“other” is))
Why do you want to join InfraGard? Check all that apply. (drop down: Assist with
the Protection of U.S. Critical Infrastructure, Networking, Liaison with FBI, Liaison with
Other LE, Attend Meetings, Access IG Network, Access iGuardian, Participate on
National or Local Board, Other (include short field to describe what “other” is))

InfraGard Application
Revised 01/16/2014

7

INFRAGARD CODE OF ETHICS
As an InfraGard member I will do all of the following:
Promote the protection of the critical infrastructure of the United States of
America.
Cooperate with others in the interchange of knowledge and ideas for mutual
protection, and participate in local, regional, and national InfraGard events to the
best of my ability.
Support the education of members and the general public about the importance
of the security of and threats to the U.S. critical infrastructure.
Serve the interests of InfraGard and the general public in a diligent, loyal, and
honest manner, and not knowingly be a party to any illegal or improper activities
that endanger the U.S. critical infrastructure.
Maintain the confidentiality, and prevent the use for competitive advantage at the
expense of other members, of information obtained in the course of my
involvement with InfraGard, which may include information concerning the
business of a fellow member or company and information identified as
proprietary, confidential, or sensitive.
Not commercially exploit InfraGard or use it as a forum to market products or
services.
Not use my affiliation with InfraGard to elicit special privileges.
Act in a manner consistent with the InfraGard National Members Alliance (INMA)
Bylaws and the local InfraGard Members Alliance (IMA) Bylaws, understanding
that the Bylaws may be amended from time to time, as well as any other duly
enacted national or local requirements of InfraGard.
Protect and respect the privacy rights, civil rights, and physical and intellectual
property rights of others.

I agree to abide by the InfraGard Code of Ethics and understand that not doing so
may result in the revocation of my membership in InfraGard. (mandatory check box)

InfraGard Application
Revised 01/16/2014

8

INFRAGARD INFORMATION SHARING POLICY
InfraGard members may receive information that is sensitive and not publicly available.
This information may be provided by or through the FBI, the InfraGard National
Members Alliance, a local InfraGard chapter, another InfraGard member, partners of
InfraGard, or other sources. Note that members are not obligated as a condition of
InfraGard membership to disclose any information to the FBI, the InfraGard National
Members Alliance, or any InfraGard chapter, member or partner; however, the key
mission of InfraGard is the effective exchange of information in order to protect the
nation’s critical infrastructure and such a goal cannot be optimally achieved if InfraGard
members do not choose to share information.
All members must understand and agree to the following terms regarding information
received or provided through InfraGard:
Non-Disclosure: Information obtained through InfraGard shall not be released
beyond its intended scope of disclosure, as established or understood, formally
or informally.
FBI Disclaimer: The FBI provides information to InfraGard members as a
service and for informational purposes only. While the FBI strives to make this
information as timely and accurate as possible, it cannot provide any warranties,
and expressly disclaims liability, for the accuracy of information disseminated
through InfraGard. The member acknowledges that he/she must use his/her own
judgment in assessing the nature and accuracy of all InfraGard-related
information and agrees to assume all risk for taking, or not taking, any action(s)
based on such information.
Submission in Good Faith: Applicant agrees that he/she will submit information
only to further the purpose of InfraGard and will not submit information which
he/she knows to be false.
Protection of Information from Disclosure: To the extent appropriate,
reasonable, and allowed by law, the FBI agrees that proprietary information
received from InfraGard members and marked as “trade secrets” or “proprietary
information” shall be protected from mandatory agency disclosure under 5 USC
552(b)(4) (“Exemption 4”), the Freedom of Information Act (”FOIA”), and from
publication, divulgence, or release in any other manner pursuant to 18 USC
1905, the Trade Secrets Act.
I understand and agree to the InfraGard Information Sharing Policy and
understand that not following such a policy may result in the revocation of my
membership in InfraGard. (mandatory check box)
InfraGard Application
Revised 01/16/2014

9

PRIVACY ACT STATEMENT
Authority: Collection of the information on this form is authorized under 28 USC 534
and 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
applicants and members. 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
IG Network and the authorization to receive information through InfraGard. The
information provided 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. It will be used to facilitate accurate identification and to help eliminate the
possibility of misidentification.
Effects of Non-disclosure 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. Knowingly falsifying or
concealing information requested on this form will result in your application being
rejected or your membership revoked. In addition, 18 USC 1001, provides that
knowingly falsifying or concealing a material fact may under certain circumstances
constitute a felony resulting in fines and/or imprisonment.

I understand and agree with the Privacy Act Statement. (mandatory check box)

InfraGard Application
Revised 01/16/2014

10

AGREEMENTS TO HOLD HARMLESS
Agreement to Hold Harmless the U.S.: The applicant agrees not to institute, initiate,
prosecute, or in any way aid in any demand, action, suit, or other claim, legal or
otherwise, against the FBI, the Department of Justice, or the United States, or the
officers, employees, agents, representatives, task force members,
contractors/subcontractors, consultants, or advisors thereof, on account of any damage,
loss, injury, or expectation arising from, in connection with, or in any way pertaining to
the reporting, non-reporting, or use of information in accordance with this agreement.
Agreement to Hold Harmless Other InfraGard Members: The applicant agrees not to
institute, initiate, prosecute, or in any way aid in any demand, action, suit, or other claim,
legal or otherwise, against any other InfraGard member on account of any damage,
loss, injury, or expectation arising from, in connection with, or in any way pertaining to
the reporting, non-reporting, or use of information in accordance with this agreement,
and the member further expressly agrees to hold harmless and indemnify the same
against loss from any and all claims that may hereafter be brought against the same by
applicant arising out of the reporting, non-reporting, or use of information.

I understand and agree to the Agreements to Hold Harmless.

APPEALS PROCESS
An applicant who is denied InfraGard membership will be notified via e-mail. Should the
applicant wish to request additional information and/or appeal the decision, he/she must
send a letter to the National Industry Partnership Unit (NIPU) via postal mail within 60
days of having received the e-mail. The e-mail will contain specific instructions about
what to include in the letter, as well as the NIPU mailing address. A letter of appeal
must address the specific reason(s) for denial. All subsequent communications
regarding the membership decision will be exchanged via postal mail.

I understand the Appeals Process.

InfraGard Application
Revised 01/16/2014

11

CONSENT
By completing 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 information obtained through InfraGard. I further
authorize the FBI to disclose information obtained in connection with my security risk
assessment to appropriate national security and law enforcement partners in order to
determine my suitability for membership in InfraGard. I understand that the FBI will use
all information provided on this application and through the record checks completed
during the security risk assessment to make a decision on my membership. I also
understand that, should I be approved for membership, the FBI will utilize the
information I have provided herein to conduct periodic reassessments of my suitability
to remain an InfraGard member.
I understand that the FBI retains sole authority and discretion to accept, deny, or revoke
the membership of any InfraGard member. I understand that I may cancel my
membership at any time upon written notice to the local InfraGard Coordinator or
National Membership Coordinator.
I understand that this is a legally binding document and false statements provided by
me are violations of federal law and could lead to criminal prosecution or other legal
action. To the best of my knowledge and belief, I affirm that I meet all of the
requirements to apply to be an InfraGard member and that the information I have
provided herein is true, complete, and correct.

I consent to the security risk assessment and to periodic reassessments.
(mandatory check box)

Provide option for applicant to either print or save completed application.

InfraGard Application
Revised 01/16/2014

12