Name:      Position/Title:
Employer:

OFFICE/SCHOOL ADDRESS:
Address 1:   
Address 2:
City: State: Zip:
Phone: Please use (XXX) XXX-XXXX format.
Fax: Please use (XXX) XXX-XXXX format.

HOME ADDRESS:
Address 1:   
Address 2:
City: State: Zip:

Email:
(Required Field: Please provide e-mail for membership updates, seminar notifications, and other benefits.)

Other Professional Certifications:

Please Select the Following:
Status: New Application   Renewal 

Membership Class (Membership year is September 1st through August 31st):
Full or Active ($20.00/year) — open to all CFEs at $20.00 per year.
Associate ($30.00) — open to associates of the Association of Certified Fraud Examiners.
Affiliate ($30.00) — open to non CFEs, non-associates and/or non-students employed in one of the above fields or interested in the purpose of the Chapter.
Student ($5.00) — open to full-time students currently enrolled in degree granting programs of accredited colleges or universities.

Preferred Mailing Address: Office/School  Home 

NEW MEMBERS ONLY:
Please furnish two Professional References, one must be a current chapter member.
Name:   Title:
Relationship:
Phone: Please use (XXX) XXX-XXXX format.

Name:   Title:
Relationship:
Phone: Please use (XXX) XXX-XXXX format.

Signature: (Please enter your initials as your "virtual" signature.)
Date of Application: (MM/DD/YYYY)

OPTIONAL:
If a hard copy of this form is desired for your records, click Print Form before clicking Submit below.

Click Submit to complete your form: