Regular/Associate Membership Application

To submit an NYSSIU application: (1) complete this webform and click “Send form”; and then (2) pay your dues online using the widget below (two-step process):

Your Name (required)*
First Last
Employer*
Work Address*
Street Address Address Line 2 City State ZIP Code
Your Email (required)*
Work Phone*
Cell Phone*
Job Title*
Supervisor's Name*
E-Signature*
Membership Type*
Today's Date*
MM slash DD slash YYYY
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I have read the above criteria for NYSSIU membership and warrant that I qualify for regular or associate membership.
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My full time assignment is to an SIU within an insurance company of a self-insured corporation.
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I understand this application is subject to acceptance by the Board of Directors and further that if my employment duties change so as to fall outside the requirements for membership, my membership in the organization shall terminate.
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I hereby make application for membership in the New York State Chapter of Special Investigation Units, Inc., in accordance with its Constitution and By-Laws and agree to be bound thereby.
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