Membership Application

Membership Level: First Name: Last Name: Birth Year (4 Digit / YEAR ONLY) Email: Home Phone: Home Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Employer: Title: Business Address Line 1 Business Address Line 2 City State Zip Work Phone: Are you presently a member of the IAAI's International Chapter? Yes No Are you presently a member of another chapter of the IAAI and if so what chapters? Have you ever been convicted of a crime, felony or misdemeanor? *Note: A yes answer to this question may affect your acceptance as a member of CTIAAI and will also incur additional required information to the BOD. Yes No Have you ever been denied membership in, or had your membership suspended, or revoked by the IAAI, any affiliate Chapter, or any other fire service/law enforcement or other organization? *Note: A yes answer to this question may affect your acceptance as a member of the CTIAAI and will require additional information be furnished to the CTIAAI BOD Yes No