U.S. Federal I.D. No. 23-7067291
www.isaca.org
[email protected]
ACADEMIC ADVOCATE
MEMBERSHIP APPLICATION
MR.
MS.
OTHER _______________Date_____________________
MONTH/DAY/YEAR
Name_______________________________________________________________________________________________________
FIRST
MIDDLE
LAST/FAMILY
University Name _____________________________________________________________________________________________
University Address_____________________________________________________________________________________________
STREET
_____________________________________________________________________________________________
CITY
STATE/PROVINCE/COUNTRY
POSTAL CODE/ZIP
University phone ____________________________________ University Facsimile ______________________________________
AREA/COUNTRY/CITY CODE AND NUMBER
AREA/COUNTRY/CITY CODE AND NUMBER
Home address
_____________________________________________________________________________________________
STREET
_____________________________________________________________________________________________
CITY
STATE/PROVINCE/COUNTRY
Home phone
_____________________________________ AREA/COUNTRY/CITY CODE AND NUMBER
E-mail
________________________________________________________
Send mail to
I do not want to be included on
a mailing list, other than for
association mailings.
Home
University
Certifications obtained
(other than CISM, CISA, CGEIT, CRISC)
1 CPA
2 CA
3 CIA
4 CBA
5 CCP
6 CSP
7 FCA
8 CFE
9 MA
10 FCPA
11 CFSA
12 CISSP
99 Other ________
Payment due
• Association dues US $135.00 • Chapter dues (see attached)
PLEASE PAY THIS TOTAL*
ISACA Chapter
ISACA Event
ISACA Journal
Do not remember
Email
ocial Media
S
Tradeshow/Seminar
Web Advertisement
Web Site Reference
Other
Current professional activity
16 Professor/Teacher
1
2
3
4
5
6
Primary Functional Area (check one)
1 Audit/Accounting/Information Systems
2 Information Security/Cybersecurity
3 Enterprise Governance of IT/MIS
4 IT Risk Management
5 Other ________
Department
__________________________________
(check the number of years of Information
Systems teaching experience)
No experience
1-3 years
4-7 years
8-9 years
10-13 years
14 years or more
$WAIVED(US)
$
(US)
$
(US)
___________________________________________________
By applying for membership in ISACA, members agree to hold the
association and its chapters, and the IT Governance Institute, and their
respective officers, directors, members, trustees, employees and agents,
harmless for all acts or failures to act while carrying out the purposes of the
association and the institute as set forth in their respective bylaws, and they
certify that they will abide by the association’s code of professional ethics
(www.isaca.org/ethics).
Full payment entitles new members to membership from the date payment
is processed by ISACA International Headquarters through the end of that
year. No rebate of dues is available upon early resignation of membership.
Method of payment
Check payable in US dollars, drawn on US bank
American Express
mployer
E
Friend/Colleague
Postal Mail
Professor/Teacher
Publication
Teaching experience
Membership dues are nonrefundable and nontransferable.
VISA
AREA/COUNTRY/CITY CODE AND NUMBER
How did you hear about ISACA?
*Membership dues consist of association dues and chapter dues.
MasterCard
POSTAL CODE/ZIP
Home facsimile ________________________________________
Diners Club
Discover
All payments by credit card will be processed in US dollars
Account #___________________________________________
Print name of cardholder________________________________
Expiration date_______________________________________
MONTH/YEAR
Signature____________________________________________
Cardholder billing address if different than address provided above:
___________________________________________________
Contributions, dues or gifts to ISACA are not tax deductible as charitable
contributions in the US. However, they may be tax deductible as ordinary
and necessary business expenses.
Make checks payable to:
ISACA
Mail your application and check to:
ISACA
1055 Paysphere Circle
Chicago, IL 60674 USA
Phone: +1.847.253.1545 x5562
Fax: +1.847.253.1443
Degree program
The university of_______________________________________offers course(s) in: (Check all that apply)
Audit/Accounting/Information Systems
Information Security/Cybersecurity
Enterprise Governance of IT/MIS
IT Risk Management
University web site url:_________________________________________________
The names of the degrees are as follows: (specify undergraduate or graduate)
__________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________
Qualifications:
ISACA offers complimentary membership for up to two faculty members per functional discipline, such as Audit/Accounting/Information Systems,
Information Security/Cybersecurity, Enterprise Governance of IT/MIS, and IT Risk Management. In educational institutions offering degree programs and
executive/Masters programs in Business, Finance, and/or Computer Science.
I certify that I meet the qualifications above to be an ISACA Academic Advocate.
__________________________________________
signature required
Library Trial subscription ISACA Journal
The following is required information for the application of Academic Advocate. A complimentary 3-month trial subscription of the ISACA Journal will be
provided to your library.
Date:_______________________________
Month/Day/Year
Prefix:
Mr.
Ms.
Other:_____________________________ (specify)
Librarian name:_____________________________________________________________________________________________________________
First Middle
Last/Family
Library e-mail address:_______________________________________________________________________________________________________
Library name:_______________________________________________________________________________________________________________
Street address:_____________________________________________________ City:____________________________________________________
State/Province:_______________________________________ Zip Code:__________________ Country______________________________________
Phone:____________________________________________________________ Facsimile:________________________________________________
Area/Country Code and Number
Area/Country Code and Number
Prospective Academic Advocates must verify their status in one of these ways:
1. Attach an Eligibility Letter to the application. The Eligibility Letter on university letterhead should be signed by the head of the department, stating
that the applicant is a full or part-time faculty member, or a recognized adjunct instructor, and verifying the degrees offered by the university in
disciplines covering areas of audit, accounting, information systems, information security, cybersecurity, enterprise governance of IT/MIS and/or IT risk
management.
2. Provide links to the university web site pages, showing the faculty status of the applicant, and verifying the degrees offered by the university in
disciplines covering areas of audit, accounting, information systems, information security, cybersecurity, enterprise governance of IT/MIS and/or IT risk
management.
— End of Application-Local Chapter Dues Follow —
US dollar amounts listed below are for Academic Advocate local chapter
dues. While correct at the time of printing, chapter dues
are subject to change without notice. Please include the appropriate
chapter dues amount with your remittance. If you have any
questions regarding chapter dues, please contact your local
chapter at www.isaca.org/chapters.
ChapterChapter
Name
NumberDues
ChapterChapter
Name
NumberDues
ChapterChapter
Name
NumberDues
ChapterChapter
Name
NumberDues
ASIA
EUROPE/AFRICA
Vancouver, BC
Victoria, BC
Winnipeg, MB
Atlantic Provinces
Ottawa Valley, ON
Toronto, ON
Montreal, PQ
Quebec City, PQ
Atlanta, GA
Charlotte, NC
Research Triangle
Bahrain Dhaka, Bangladesh
China Hong Kong
Bangalore, India
Cochin, India
Coimbatore, India
Hyderabad, India
Kolkata, India
Chennai, India
Mumbai, India
New Delhi, India
Pune, India
Vijayawada, India
Indonesia
Fukuoka, Japan Nagoya, Japan
Osaka, Japan
Tokyo, Japan
Korea Lebanon
Macao
Malaysia
Muscat, Oman
Islamabad, Pakistan
Karachi, Pakistan
Lahore, Pakistan
Manila, Philippines
Jeddah, Saudi Arabia
Riyadh, Saudi Arabia
Singapore
Sri Lanka
Taiwan
Bangkok, Thailand
UAE
208
$0
207
$0
64
$0
138 $10
176
$0
155
$0
164
$0
165 $15
99
$0
145
$0
140
$0
159
$0
200
$0
123$45
219
$0
118 $60
103 $85
89
$0
107
$0
181$35
190$0
93$0
168 $15
224 $10
148
$0
196 $10
136
$0
163 $25
154
$0
70$0
141
$0
142$0
109
$0
150$0
LATIN AMERICA
Buenos Aires, Argentina 124
S
Mendoza, Argentina
144
$0
LaPaz, Bolivia
173 $25
Brasília, Brazil
202
$0
Rio de Janeiro, Brazil 203
$0
São Paulo, Brazil
166
$0
Santiago, Chile
135
$0
Bogotá, Colombia
126 $25
San José, Costa Rica
31
$0
Santo Domingo,
Dominican Republic 226 $20
Quito, Ecuador
179 $30
Guatemala City, Guatemala 215 $15
Guadalajara, México 201 $15
Mexico City, México 14$0
Monterrey, México 80$0
Panamá
94$0
Asunción, Paraguay
184
$0
Lima, Perú
146
$0
Puerto Rico
86
$0
Montevideo, Uruguay
133
S
Venezuela
113$0
* Contact chapter for information
Austria
Belgium Gaborone, Botswana Sofia, Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
Paris, France
Germany
Accra, Ghana
Athens, Greece
Budapest, Hungary
Ireland
Tel-Aviv, Israel
Milan, Italy
Rome, Italy
Venice, Italy
Kenya
Latvia
Lithuania
Luxembourg
Malta
Mauritius
Netherlands
Abuja, Nigeria
Ibadan, Nigeria
Lagos, Nigeria
Norway
Katowice, Poland Warsaw, Poland
Lisbon, Portugal
Moscow, Russia
Romania
Slovenia
Slovak Republic
South Africa
Barcelona, Spain
Madrid, Spain
Valencia, Spain
Sweden
Switzerland
Tanzania
Tunis, Tunisia
Ankara, Turkey
Istanbul, Turkey
Kampala, Uganda
Kyiv, Ukraine
London, UK
Central UK
Northern England, UK
Scotland, UK
Winchester, UK
Lusaka, Zambia
157$0
143
$0
228 $30
189
$0
170$0
210$0
153
$0
96$0
162$25
115$0
75
$0
104$0
205 $20
134
$0
125
$0
156$0
40
$0
43
$0
178 $26
216 $25
158$20
139$20
180$0
198$60
186$0
211$10
97$0
185
$0
222
$0
149
$0
74$0
220 $30
218
$0
209
$0
167
$0
172$0
137$0
160
$0
130
$0
171
$0
183
$0
182
$0
88$0
116$0
174$50
225
$0
217 $10
204 $40
199 $50
206
$0
60
$0
132
$0
111
$0
175
$0
212 $10
223 $20
NORTH AMERICA
Canada
Calgary, AB
Edmonton, AB
121
131
$0
$0
25
100
72
105
32
21
36
91
$0
$0
$0
$0
$0
$0
$0
$45
39
51
59
$5
$0
$0
South Carolina Midlands 54
$0
(Raleigh, NC)
(Columbia, SC)
Memphis, TN
Middle Tennessee
48
102
$25
$0
(Nashville)
Islands
Bermuda
Curacao Trinidad & Tobago
147$0
227 $15
106
$0
Midwestern United States
Central Indiana 56
$0
(Indianapolis)
Chicago, IL
02
$0
Illini (Springfield, IL)
77$0
Illowa
169$0
Iowa (Des Moines)
110$0
Kentuckiana (Louisville, KY)37 $0
Detroit, MI
08
$0
Western Michigan
38
$0
(Grand Rapids)
Minnesota (Minneapolis) 07$0
Omaha, NE
23
$0
Central Ohio (Columbus)
27$0
Greater Cincinnati, OH
03
$0
Northeast Ohio (Cleveland) 26$0
Northwest Ohio
188 $30
Kettle Moraine, WI
57
$0
(Milwaukee)
$0
$0
(Baltimore)
18
30
29
$0
$15
$0
120
$0
10
46
$0
$0
(Syracuse)
Hudson Valley, NY
Western United States
Anchorage, AK
177
Phoenix, AZ
53
Los Angeles, CA
01
Orange County, CA
79
$0
$0
$0
$0
Sacramento, CA
San Francisco, CA
San Diego, CA
Silicon Valley, CA
76
15
19
62
$0
$0
$0
$0
(Sunnyvale)
Hawaii (Honolulu)
Boise, ID
Las Vegas, NV
Willamette Valley, OR
71$0
42
$0
187
$0
50
$0
(Portland)
(Albany)
New York Metropolitan
Western New York
(Little Rock)
Denver, CO
16
$0
Baton Rouge, LA
85
$0
Greater New Orleans, LA61 $10
Greater Kansas City, MO 87
$0
Springfield, MO 214
$0
St. Louis, MO
11
$0
New Mexico (Albuquerque)83 $25
Central Oklahoma (OK City) 49$0
Tulsa, OK
34
$0
Austin, TX
20
$0
Greater Houston Area, TX09 $0
North Texas (Dallas) 12$0
San Antonio/So. Texas 81
$0
(Anaheim)
Northeastern United States
Greater Hartford, CT
28
(Southern New England)
Central Maryland
24
New England New Jersey
Central New York
Virginia
22$0
­­­Southwestern United States
Central Arkansas
82 $30
(Buffalo/Rochester)
Harrisburg, PA
45
$0
Philadelphia, PA
06
$0
Pittsburgh, PA
13
$0
Rhode Island
197
$0
National Capital Area, DC 05$0
Southeastern United States
Birmingham, AL
65$0
Huntsville, AL
221
$0
Central Florida (Orlando)67 $0
Jacksonville, FL
58
$0
South Florida
33
$0
Tallahassee, FL 213
$5
West Florida (Tampa) 41$0
Utah (Salt Lake City)
04$0
Mt. Rainier, WA (Olympia) 129$0
Puget Sound, WA (Seattle) 35$0
OCEANIA
Adelaide, Australia
68
$0
Brisbane, Australia
44
$5
Canberra, Australia
92
$0
Melbourne, Australia
47
$0
Perth, Australia
63
$0
Sydney, Australia
17
$0
Auckland, New Zealand
84$0
Wellington, New Zealand73 $0
Papua New Guinea
152
$0