Private Sector Partner RegistrationPlease complete the form below, no partial applications accepted.
CONTACT INFORMATIONFirst Name *Last Name *Position / Title: *Phone Work: *Mobile Phone:Email: * (Organization email addresses only)
WEBSITE ACCESSPassword: *Create a password for site / modify contact information)INFRAGARD MEMBERSHIPCurrent Infragard Member? Yes NoInfragard Chapter Name:Infragard Membership #:Scan and attach your Infragard membership card :SECURITY CLEARANCE
Do you have a Security Clearance?: Yes -Select-SECRETTOP SECRETN/A NoCleared Through: FBI DOD DHS N/AIf cleared through other state below:
COMPANY / ORGANIZATION NAME *City: *County: *- Select your county -AlamedaContra CostaDel NorteHumboldtLakeMarinMontereyNapaMendocinoSan BenitoSan FranciscoSan MateoSanta ClaraSanta CruzSonomaOtherState *
SUPERVISOR / EMPLOYMENT VERIFICATION CONTACTFull Name*Supervisor's Title*Supervisor's Email Address:* (Organization email addresses only)Confirm Your Supervisor's Email Address:* BACKGROUND INFORMATIONHave you ever been convicted of felony? *Yes NoHave 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
DESCRIPTION OF FACILITY OR NATURE OF BUSINESS* Description is required to substantiate the need for inclusion in the NCRIC
Other Sector (please specify)
1. I hereby accept the obligations contained in this Agreement in consideration of my being granted access to FOUO information. As used in this agreement, FOUO information is marked or unmarked FOUO information, including oral communication, which is FOUO information under the standards of the NCRIC. I understand and accept that being granted access to FOUO information, special confidence and trust shall be placed in me by the NCRIC.
2. I hereby acknowledge that I have read the attached document, titled "Safeguarding Sensitive but Unclassified Information" and a copy has been provided to me, and that I have received a security indoctrination concerning the nature and protection of FOUO information, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.
3. I have been advised that the unauthorized disclosure, unauthorized retention, or negligent handling of FOUO information by me could cause damage or irreparable injury to the NCRIC. I hereby agree that I will never divulge FOUO information to anyone unless: (a) I have officially verified that the recipient has been properly authorized by the NCRIC to receive it; or(b)I have been given prior authorization from the agency responsible for the information that such disclosure is permitted; or (c) the recipient has the "need to know" in order to perform their official duties. I understand that if I am uncertain about the classification status or handling control authority of information received from the NCRIC, I am required to confirm from an authorized NCRIC official that the information is FOUO before I may disclose it, except to a person as provided in (a) or (b) above.
4. I have been advised that any breach of this Agreement may result in the termination of my affiliation with the NCRIC.
5. I have read this agreement carefully and my questions, if any, have been answered.