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CONTACT INFORMATION
First Name *
Last Name *
Position / Title / Rank: *
Work Phone: (###-###-####) *
Mobile Phone: (###-###-####)
Email: * (Organization Email Addresses Only)
WEBSITE ACCESS
Password: *
Create a password for site
INFRAGARD MEMBERSHIP
Currently an Infragard Member?
Yes No
Infragard Chapter Name:
Infragard Membership #:
Scan and attach your Infragard membership card :
SECURITY CLEARANCE
Do you have a Security Clearance?:
Yes No
Cleared Through:
FBI DOD DHS N/A
If cleared through other state below:
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COMPANY / ORGANIZATION NAME *
Address: *
Address 2:
City: *
County: *
SUPERVISOR / EMPLOYMENT VERIFICATION CONTACT
Supervisor Full Name*
Supervisor Title*
Work Phone:* (###-###-####)
Supervisor's Email Address:*
(Organization Email Addresses Only)
Confirm Your Supervisor's Email Address:*
BACKGROUND INFORMATION
Have you ever been convicted of felony? *
Yes No
Have you been convicted of misdemeanor in the last 7 years? * Yes No
(if yes describe below)
Are you a U.S. Citizen or
Legal Permanent Resident? *
Yes No
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