Certification for Educators Grandfathering Provision Application v.2

INSTITUTE FOR INTERNAL CONTROLS CERTIFICATION FOR EDUCATORS GRANDFATHERING PROVISION APPLICATION
NOTE: (1) THIS FORM IS LIMITED TO FULL TIME FACULTY FROM ACCREDITED UNIVERSITIES / COLLEGES IN NORTH AMERICA, EUROPE, PHILIPPINES AND AUSTRALIA. (2) APPLICANTS FROM OTHER COUNTRIES MUST CONTACT THE OFFICE OF THE CHAIRMAN (chairman@theiic.org) FOR CONSULTATION BEFORE APPLYING UNDER THIS CERTIFICATION PROGRAM. **ADJUNCT FACULTY ARE NOT ELIGIBLE FOR CERTIFICATION UNDER THIS PROVISION.

INSTRUCTIONS: Educators may be eligible for the Certification via Educator Program based on education, experience, development or delivery of courses in the appropriate areas of internal controls, or publication of high quality articles in areas of internal controls in peer-reviewed journals. Areas include Accounting, Computer Science/IT, Information Security, Physical Security, Management, Quality Controls, etc. Educators must be employed full-time as a faculty member at an accredited university as recognized by the Association of Schools & Universities (for U.S. schools) or an acceptable accrediting agency (for non-U.S. schools). Educators receive a 50% discount on application fees and annual renewal fees, as well as additional discounts on training and conferences. Proof of full-time employment may be requested.

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Certification *

CICA CCS
Applicant Instruction Acknowledgement *

I have read, understand and agree to the application instructions and requirements above, including the timing process for processing application, notification of committee;s decision, mailing and receipt of certificate (if approved)
Applicant Employment Declaration *

I AM employed as a full-time faculty member at an accredited college or university.
Application Date

Month Day Year
Personal Information

Please include all the personal information requested here to the best of your ability.
Salutation *
First Name *
Middle Name
Last Name *
Home Address *

Street Address

P.O.Box (if any)

City State / Province

Postal/Zip Code (If you are applying from a country that does not utilize postal codes or zip codes, Type “N/A” or NONE. This field is not for PO Boxes) Country
Personal E-mail *
*Very Important: you cannot use your work address for your local residence or your work email as your personal email. Likewise, you MUST include both your personal and work email addresses. The preferred email address you provide is the unique identifier that is used for your account. If you are intending to obtain a second certification with TheIIC you must utilize a different email address for the second certification. If you do not provide a different email address your application for the second certification will be halted until a new email address is provided as the unique identifier.
Academic Employment Information

Enter all required information regarding your academic employment to the best of your ability.
Academic Institution *
Title
Your Faculty Webpage IP Address *
Work Mailing Address

In the spaces below provide your work address at your institution of higher education, including the name of the school and the department you are a member of. Be sure to include all information requested in order than materials mailed to you are received as quickly as possible.
Work Address *

School/Department

Street Address

City State

Postal/Zip Code (If you are applying from a country that does not utilize postal codes or zip codes, Type “N/A” or NONE. This field is not for PO Boxes) Country
Personal Phone *

Country Code Area Code Phone Number
Work Phone *

Country Code Area Code Phone Number
University E-mail *
Preferred Mailing Address *

Business Home
Preferred E-Mail Address *

Business Home
Have you ever been convicted of a felony? *

Yes No
If Yes, explain: (Limit 100 words)

0/100

Qualifications
Academic Employment Status *
Check Applicable Box: *

*I have taught a minimum of 4 courses in Internal Controls and/or related fields for each of the past 3 years *I have published peer reviewed scholarly works in the areas of Internal Controls *I have both taught a minimum of 4 courses AND published peer reviewed scholarly works in the areas of Internal Controls
List all Internal Controls related courses taught, including credits awarded for each: (Limit 100 words)

0/100
Click to Upload Submissions of publications referenced above in publication format only.

Upload a File

Cancel of
Please include anything you wish to add to your application here: (Limit 100 words)

0/100
Applicant's Electronic Signature

WARNING: UNSIGNED APPLICATIONS WILL BE REJECTED!
Type your name in the box below, followed by /es/ to represent your signature *

Submit and Pay
If paying by credit card select the credit card box below. Note: Be advised that Affinipay is providing services as TheIIC's CC bank/vendor. If Affinipay does not operate in your country, contact membership@theiic.org immediately for a link to use an alternative CC vendor. No action on your application will be considered before receipt of payment in full.

If paying by Check or Money Order (PAYABLE ON A US BANK ONLY) Select the appropriate box to send your completed application to the IIC. Send your Check or Money Order in the amount of $100.00 to:

Institute for Internal Controls Inc.

Attn: Nominations Committee

109 Mullen Drive

Sicklerville, NJ 08081

USA

Note: No application will be considered before the receipt of full payment.

NOTE: You MUST click the PRINT button on the “Submit and Pay” tab to provide a hardcopy of this form. You may not be able to print out a copy of the form for your records once you click the SUBMIT button.
Choose your method of payment: *

Credit Card Check or Money Order sent by Applicant or Applicant's Employer
Should be Empty:

INSTITUTE FOR INTERNAL CONTROLS CERTIFICATION FOR EDUCATORS GRANDFATHERING PROVISION APPLICATION

Applicant's Electronic Signature

WARNING: UNSIGNED APPLICATIONS WILL BE REJECTED!